Anthem Blue Cross and Blue Shield Serving Hoosier Healthwise

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Anthem Blue Cross and Blue ShieldServing
Hoosier Healthwise
Anthem Blue Cross and Blue Shield is the trade
name of Anthem Insurance Companies, Inc.
Independent licensee of the Blue Cross and Blue
Shield Association. ANTHEM is a registered
trademark of Anthem Insurance Companies, Inc. The
Blue Cross and Blue Shield names and symbols are
registered marks of the Blue Cross and Blue
Shield Association.

• State Sponsored Business

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Overview

• Prior Authorization (PA)
• Adjustments Claims Reconsideration
• Appeals
• Durable Medical Equipment

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We Are Local

• We are not just another health plan..
• We are your neighbor!

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Member Eligibility

• Helpful Hints
• You should verify the members eligibility prior
  to services.
  
• You are able to check member eligibility through
  the Anthem website www.anthem.com.
  
• Members are issued 2 cards
• One card from the State listing the Medicaid .
• One card from Anthem Hoosier Healthwise listing
  the ID beginning with a prefix of YRH.
  

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Prior Authorization

• Prior Authorization Toolkit listed on our
  website www.anthem.com
  
• Services Requiring Prior Authorization.
• Request for Preservice Review
• Non-par providers all services require prior
  authorization

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Prior Authorization

• Participating Providers A few services require
  prior authorization such as
  
• DME services
• Home health care services
• Hearing aids
• Inpatient hospital services (elective and
  emergent admissions)
  
• Sleep studies
• Radiology services
• Skilled Nursing Facility care
• Transplant services
• Surgery inpatient and outpatient
• See materials insert for a more inclusive list.

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Prior Authorization

• Services that Do NOT require prior
  authorizations
  
• Chiropractic services limitations noted
  depending on members selected package
  
• Dialysis
• Emergency services notify Anthem of admissions
  within 24 hours or the next business day of
  inpatient admits
  
• Formulary nebulizers
• Family planning/Well-woman check up member may
  self-refer to any Medicaid provider for the
  following services
  
• Pelvic and breast examinations
• Lab work
• Birth control
• Genetic counseling
• FDA approved devices and supplies related to
  family planning
  
• HIV/STD screening

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Prior Authorization

• Services that Do NOT require prior authorizations
  (continued)
  
• Laboratory services an in-network hospital
  laboratory is to be utilized for all laboratory
  needs.
  
• Nutritional counseling no authorization is
  required for 97802, 97803 and 97804
  
• Obstetrical care no authorization is required
  for in-network physician visits, routine testing
  and inpatient delivery.
  
• Lab, selective imaging studies (see section on
  radiology services and outpatient hospital
  services) and most diagnostic procedures such as
  colonoscopies, endoscopies and mammograms.
• No PA required for physician referrals if
  referring to an in-network specialist for
  consultation
  
• Radiation therapy
• Standard x-rays and ultrasounds
• In-network physical therapy, occupational therapy
  and speech therapy

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Prior Authorization

• Include the following on the Request for
  Preservice Review
  
• Member name and ID including the YRH prefix
• Diagnosis with ICD-9 code
• Procedure with CPT/HCPCS code
• Date of injury/date of hospital admission
• Facility name (if applicable)
• Requesting physician name
• Clinical information supporting request

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Prior Authorization

• Phone [phone]
• Fax [phone]
• Timeframe usually a three day turnaround time.
• If request has missing information, it may take
  longer.
  
• If you have an urgent request, please call and
  indicate this to the Intake Specialist.
  
• Note An urgent request means that a delay in
  the authorization would be detrimental to the
  members health.

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Prior Authorization

• PHARMACY
• Preferred Drug List (Formulary) is available
  through the Anthem website www.anthem.com
  
• Epocrates is a drug reference software
  application that allows you to check
  
• Formulary status
• Prior authorization requirements
• Formulary alternatives
• General substitutes
• Quantity limits

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Prior Authorization

• Pharmacy (continued)
• Epocrates also features drug reference
  information including
  
• Indication
• Dosing
• Contradictions
• Drug interactions
• Adverse reactions
• Cost information
• Epocrates website www.epocrates.com

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Prior Authorization

• Pharmacy (continued)
• Prior authorization applies to select
  medications.
  
• You may view medications requiring PA on
  www.anthem.com.
  
• You may download various medication PA forms.
• Complete and fax the Medication Prior
  Authorization Form to WellPoint NextRx at
  1-866-408-7103.
  
• You may call for medication PA questions to
• 1-877-652-1223.

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Claims Reconsideration

• Timely filing limit
• In-network providers 180 Days for Professional
  
  
• 365 Days for Institutional
• Out-of-network providers 365 Days
• Providers may request a reconsideration of a
  claim payment or denial.
  
• Providers would complete the Dispute Resolution
  Request Form. Refer to www.anthem.com.
  
• Providers must submit the Dispute Resolution
  Request Form within 60 days from the date you
  receive the Remittance.
  

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Claims Reconsideration

• Mail Reconsideration Requests to 
• Anthem Blue Cross Blue Shield
•    PO Box 6144  
• Indianapolis, IN 46206-6144     
•            

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Claims Overpayment Recovery

• Anthem seeks recovery of all excess claim
  payments from the payee to whom the benefit check
  is made payable. 
  
• When an overpayment is discovered, an overpayment
  recovery process is initiated by sending written
  notification of the overpayment to the
  provider. 
• Mail a copy of the overpayment notification
  and/or the EOB from Anthem or other carriers and
  a check to
  
•      Attn Cost ContainmentAnthem Blue Cross and
  Blue ShieldPO Box 9207Oxnard, CA 93031-9207

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Grievances and Appeals

• Providers can file a written grievance related to
  dissatisfaction or concern about         
  
• Another Anthem provider
• Anthem (Clinical Grievance and/or Administrative
  Grievance)
  
• A member
•  Providers may file a written appeal on behalf of
  a member for
  
• Denial of a prior authorization request
• Deferral of a prior authorization request
• Modification of a prior authorization request
• Providers may request a claim dispute appeal
• Provider Grievance and Appeals Form can be found
  on www.anthem.com.

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Grievances and Appeals

• Timelines for filing
•  
• Grievance 60 calendar days from the date the
  provider became aware of the issue.
  
•  Appeals 30 calendar days from the date of the
  notice of action letter advising of the adverse
  determination.
  
• Anthems Response/ResolutionGrievances within
  20 business days from the receiptAppeals within
  30 business days.

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Grievances and Appeals

• Complete and submit the form to
• Attn  Appeals and Complaints Department
• Anthem Blue Cross and Blue Shield
• PO Box 6144
• Indianapolis, IN 46206-6144
•          
• Complete and submit via fax to
•     1-866-387-2968

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Durable Medical Equipment

• All Physician written orders for DME supplies
  must be kept on file for audit purposes.
  
• Nonspecific HCPCS Codes
• Nonspecific HCPCS will be manually priced.
• Submit claim with documentation supporting the
  cost of the item, including a list of all
  materials.
  
• Provider must not bill more thantheir usual and
  customary.
  
• Documentation is required for prior
  authorization.
  

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Durable Medical Equipment

• Services Requiring Prior Authorization for
  In-network providers
  
• Disposable supplies, including formula/nutritional
  supplements
  
• Rental of DME and purchase of custom equipment
• Airway Clearance Vest
• Apnea monitors
• CPAP/BIPAP
• Cranial helmets
• External infusion pumps
• Hearing aids
• Hospital beds and support surfaces
• Hospital-grade breast pumps (E0604)

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Durable Medical Equipment

• Services Requiring Prior Authorization for
  In-network providers (continued)
  
• Lymphedema pumps
• Motorized and manual wheelchairs/scooters
• Osteogenic stimulators
• Oxygen therapy
• Parenteral/Enteral nutrition
• Seat lift mechanisms
• Therapeutic formulas and dietary supplements
• TENS
• Wound vacs
• Formulary glucometers
• For questions regarding other DME, please contact
  the Utilization Management department at
  1-866-408-7187.
  

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Durable Medical Equipment

• Rental vs. Purchase
• Use appropriate modifier                    
•   NU New
•   UE Used
•   RR Rental
• Base decision to rent or purchase DME on the
  least expensive option available.
  
• DME items purchased with IHCP funds become the
  property of the OMPP.

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Durable Medical Equipment

• Capped rental items
• Continuous rental is without interruption for a
  period of more than 60 days.
  
• Certain procedures codes are limited to 15 months
  of continuous rental. Refer to
  www.indianamedicaid.com.
  
• A change in provider does not cause an
  interruption in the rental period.
  

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Durable Medical Equipment

• Repair and replacement
• May require prior authorization based on HCPCS
  code.
  
• Repair of equipment still under warranty is not
  covered.
  
• Repair necessitated by member misuse or abuse,
  whether intentional or unintentional is not
  covered.
  
• Maintenance charges of properly functioning
  equipment is not covered.
  
• Replacement of large DME items may be authorized
  once every five years per member.

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Durable Medical Equipment

• Incontinence supplies
• Covered for members three years old or older.
• Order from physician must include a start and
  stop date and a detailed list of the incontinence
  supplies ordered.
  
• DME suppliers must maintain documentation of
  proof of delivery, including date of delivery,
  address and signature of member/caregiver/family
  member who received the supply.

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Durable Medical Equipment

• Oxygen and Home Oxygen Equipment
• Includes the system, vessels, tubing,
  administration sets and oxygen contents.
  
• Medical necessity is the determining criteria.
• One unit equals one month place a 1 in the
  Units field of the CMS-1500 or 837 transaction.
  
• Spare tanks of oxygen and precautionary are not
  covered.
  
• Refer to www.indianamedicaid.com for more
  information about Oxygen and Home Oxygen
  Equipment.

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Durable Medical Equipment

• Wheelchairs
• Subject to prior authorization.
• Power Wheelchairs
• A completed IHCP Medical Clearance for Motorized
  Wheelchair Purchase form signed by a physiatrist
  must be submitted with the PA request form that
  documents the members condition, mobility needs,
  and/or prognosis to support the medical necessity
  for a POV. The form is located on the IHCP Web
  site at http//www.indianamedicaid.com/ihcp/Forms
  /MedicalClearance_
• motorizedwheelchair.pdf.
• Documentation must indicate the members
  condition renders them unable to operate a manual
  wheelchair. Documentation must also indicate the
  member is capable of safely operating a POV, can
  transfer in and out of a POV, and has adequate
  trunk stability to safely ride in and operate the
  POV.
• If the item was not available before August 1,
  2003, claims must be submitted with a
  manufacturers purchase invoice, the catalog page
  that initially published the item, and the MSRP.
• Refer to www.indianamedicaid.com and the Anthem
  Provider Operations Manual on www.anthem.com.
  

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Durable Medical Equipment

• Helpful hints for electronic claim filing
• COB Medicaid claims cannot be filed
  electronically.
  
• The members ID must include the YRH prefix.
• Use the appropriate NPI.
• Include the Tax ID number.
• Include the Provider Medicaid ID Number.
• The Anthem Payor ID number is 00630.
• Review your electronic submission reports from
  Anthem.
  
• Call the Anthem EDI Help Desk if you/your vendor
  has problems with electronic claims filing.
  
• EDI Help Desk 1-800-470-9630

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Claims Durable Medical Equipment

• Helpful hints for filing paper claims
• Use the CMS-1500 or the UB-04 claim form
  dependent upon contractual agreement.
  
• The members ID must include the YRH prefix.
• Include your Tax ID number.
• Include your Medicaid ID number. COB claims must
  be filed on paper.
  
• NPI is required.
• Mail your paper claims to
• Anthem Blue Cross and Blue Shield
• PO Box 37180
• Louisville, KY 40233-7180

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Were working with health care providers to
improve the health of our communities and
thelives of the people we serve.

• Thank you!

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• QUESTIONS?