Anthem - Missouri State Medical Association

advertisement
Anthem MSMA
Presentation
April 2014
This presentation contains proprietary information of Anthem
Blue Cross and Blue Shield.
Any redistribution or other use is strictly prohibited.
Objectives
•
•
•
•
•
•
•
•
•
•
Anthem MO Provider Networks
Anthem MO Products
Member ID Cards
BlueCard
New Exchange Levels/Products/Cards
Claims Filing Guidelines
Addresses
Claim Escalation Process/Network Management
Online Self Service Tools
Question & Answer
Anthem Mo Provider
Networks
Anthem MO Provider Networks
•
•
•
•
•
•
•
Blue Access Network
Blue Access Choice Network
Blue Preferred Network
Pathway/Pathway X
Medicare Advantage Network
Federal Programs
Traditional
Member ID Cards
Member ID Cards

Members Identification Number- Member identification
numbers are found on the identification card under the
member's name. The identification numbers contain
three letter prefixes which are critical in the routing and
processing of your claim.

Network - Knowing the member’s network will assist you
in identifying the applicable reimbursement schedule.
You need to have this information when registering
members in your office.
Member ID Cards

Steps to determine reimbursement schedule:
1.
First look for Blue Access, Blue Access Choice, Blue Preferred or Pathway
network on the members id card.
2.
If you do not locate Blue Access, Blue Access Choice, Blue Preferred or
Pathway network on the id card then look at the suitcase.
3.
If the suitcase is empty or you do not locate a suitcase please contact the
number on the back of the id card, as the member may not have out of
network benefits.
•
Please remember: The suitcase identifies members with benefits when they
travel. If a member receives services outside of Anthem’s service area, that
member would need to access a provider in that Blue plan’s network to
receive in-network benefit levels.
•
(Example)-An Anthem member travels to Kansas and needs to see a Kansas
provider. If the suitcase had a PPO then the patient would need to seek out a
PPO provider in the Kansas plan to receive their maximum benefit.
Member ID Cards
BlueCard
Blue Card
• The Blue Cross and Blue Shield Association (BCBSA) is a
national federation of 39 independent, community-based and
locally operated Blue Cross and Blue Shield companies.
• BlueCard® launched in 1994. This program enables member who
are traveling or living in another Plan's service area to receive the
same healthcare service benefits of their home Plan.
What is BlueCard?
•The BlueCard® Program links health
care providers and the independent
Blue Cross and Blue Shield Plans
across the country and around the
world through a single electronic
network for claims processing
reimbursement.
•Your local Blue Plan is your single
point of contact for claims
How Blue Card Works
1. Member of
another Blue Plan
receives services
from you, the
provider
2. Provider
submits claim to
the local Blue
Plan
7. Your local
Blue Plan pays
you, the provider
3. Local Blue Plan
recognizes BlueCard
member and transmits
standard claim format to
the the member’s Blue
Plan
6. Member’s Blue
Plan transmits claim
payment disposition
to your local Blue
Plan
4. Member’s Blue
Plan adjudicates
claim according to
member's benefit
plan
5. Member’s Blue Plan
issues an EOB to the
member
Examine Insurance ID Card
Logos
BlueCross BlueShield
of Anywhere
An Independent licensee of the
Blue Cross and Blue Shield Association
DOE, JOHN
Identification No.
Group No.
XYZ123456789
123456
BS Plan Code 621
Sect.
0000
BC Plan Code 121
BlueCard:
Verifying Eligibility and Benefits
• Ask members for their current member ID
card
• Check eligibility and benefits through
Availity or by calling BlueCard Eligibility
line 1.800.676.BLUE (2583)
• Verify the member’s cost sharing amount
(copay) before processing payment
Submitting
®
BlueCard
Claims
(cont’d)
BlueCard Exclusions




FEP
Medicare Risk
Stand-alone dental and prescription drugs
Vision and hearing
Anthem Missouri Exchanges
New Provider Network
Provider Network For Individual Business ON
Exchange: Pathway X
Provider Network For Individual Business OFF
Exchange: Pathway
Same providers for both Individual business ON
and OFF Exchange
A Focused Network of professional and facility
providers
17
Missouri Metal Level Plans On and Off
Exchange
ON EXCHANGE
OFF EXCHANGE
Bronze (60% AV)
Core (60% AV)
• 6 Plans including one plan with
embedded pediatric dental
• 6 Plans including one plan with
embedded pediatric dental
Silver (70% AV)
Essential (70% AV)
• 4 Plans
• 4 Plans
Gold (80% AV)
Preferred (80% AV)
• 2 Plans including one plan with
embedded pediatric dental
• 2 Plans including one plan with
embedded pediatric dental
Anthem Small Group Products - MO
Small Group - On-Exchange
Network Name – Blue Preferred
Product
Type
Prefix
Anthem Bronze Direct Access
PPO
JWU
Anthem Silver Direct Access
PPO
JWU
Anthem Gold Direct Access
PPO
JWU
Small Group – Off-Exchange
Network Name – Blue Access, Blue
Access Choice, or Blue Preferred
Product
Type
Prefix
Anthem Core Direct Access
PPO
YCB, YCA, YCC,
YCD, YCE
Anthem Essential Direct Access
PPO
YCB, YCA, YCC,
YCD, YCE
Anthem Preferred Direct Access
PPO
YCB, YCA, YCC,
YCD, YCE
Anthem Individual Products
Missouri
Individual - On-Exchange
Network Name - Pathway X
Product Prefix
Type
Anthem Bronze Direct Access
PPO
JWZ, YCH
Anthem Silver Direct Access
PPO
JWZ, YCH
Anthem Gold Direct Access
PPO
JWZ, YCH
Individual – Off-Exchange
Network Name - Pathway
Product
Type
Prefix
Anthem Core Direct Access
PPO
JWY
Anthem Essential Direct Access
PPO
JWY
Anthem Preferred Direct Access
PPO
JWY
What Does the ID Card Look Like?
Missouri Medical Off Exchange - Individual
21
What Does the ID Card Look Like?
Missouri Medical On Exchange - Individual
22
What is the 90-Day Grace Period?
• Individual members who purchase their health plan on
the marketplace are eligible for a premium subsidy from
the government. The ACA mandates a three month
grace period for delinquent premium payments.
• It applies after the individual has paid at least one month
of premium within the benefit year.
How will the 90-Day Grace Period
be implemented?
• Anthem will process claims for services received during the first
month
• Providers notified of grace period on remittance for services
rendered during second and third month.
• During the second and third months, if payment is not received, the
health plan will be terminated, claims for services received during
the second and third month will be denied.
• Payment made for dates of service within the first month will not be
retracted
• Impacted claims will be automatically adjusted once a member pays
their premium, or is terminated (after the end of the grace period).
Anthem Claims Filing
Guidelines
Claims Filing Guidelines
•
•
•
•
•
File claims within 180 day from the date the
services were rendered or date of other carriers
EOB. ***Unless your contracts specifies something else.***
Use appropriate claim processing forms and
CMS billing codes
Claims form must have all fields completed.
File claims electronically
File claims to your local BluePlan
Addresses
Addresses
Address Use
Address
Claims
Anthem Blue Cross and Blue Shield
P.O. Box 105187
Atlanta, GA 30348
Correspondence
Anthem Blue Cross and Blue Shield
P.O. Box 105557
Atlanta, GA 30348
FEP Claims/Correspondence
Anthem Blue Cross and Blue Shield
P.O. Box 105557
Atlanta, GA 30348
Grievance and Appeals
Anthem Blue Cross and Blue Shield
P.O. Box 105568
Atlanta, GA 30348
UM Appeals
Anthem Blue Cross and Blue Shield
P.O. Box 105662
Atlanta, GA 30348
Provider Claims Escalation
Process/Network
Management
Escalation Process
In an effort to better serve Providers, we have initiated an escalation process
to assist with claim/issue resolution more quickly and efficiently. It is
critical to document the reference numbers given on both telephone
contacts and secured messaging.
Provider Service – Telephone Inquiries

We ask that you contact Provider Service initially. In the event that your
claim/issue is not handled to your satisfaction, we ask that you ask for a
supervisor. If the rep is sending your claim for adjustment or additional
research, we ask that you allow 30 days for resolution. If after the 30 day
period, your claim/issue is still unresolved, we ask that you call and
request to speak to a supervisor.
Escalation Process (cont.)
Secured Messaging (Currently in review)
 If you send a secured message and
do not receive
satisfactory response, please reply to the original secured
message and request that the inquiry be escalated to a
supervisor. Please include your name and a number where
you can be reached.
In both scenarios, once you have escalated your claim/issue please
allow 30 days for research/adjustment.
If you still require additional assistance after exhausting these
avenues, please contact your Network Consultant and provide
both reference numbers or secured message transaction
number.
In order for this procedure to work, please always allow the
front end reps the opportunity to resolve your issue first.
Improving the Provider Experience:
Provider Escalation process (continued)
Network Management continues to support questions related to:
your provider contract
fee schedule discrepancy
information about how to register and
access Anthem’s self-service tools
training and education
clarification of products or programs
offered by Anthem
Online Self Service
Tools
Online Tools
Sites to use for Anthem business:
www.Anthem.com---unsecure web portal
MyAnthem----secured web portal
www.availity.com---multi-payor portal
Self-Service Tools
Electronic Data Interchange (EDI)
• With EDI you can submit and receive transactions from your
computer system.
• Connect directly to Anthem using vendor software or through an
approved clearing house.
Transactions Available through EDI:

Claims submission

Electronic Remittance Advice

Electronic Funds Transfer

Eligibility

Benefits

Claims Status
Self Service Tools
Interactive Voice Reponses (IVR)
Phone access to real-time:

Eligibility

Benefits

Claims status
•
•
•
Use for one or multiple members
Listen to the information or have it sent via fax
FEP claims detail
Self Service Tools – ICR
(Interactive Care Reviewer)
Our new online tool offers a streamlined precertification
process using cutting-edge IBM Watson technology and
can be accessed via Availity to request inpatient and
outpatient procedures for many members covered by
Anthem and BlueCard plans. Some benefits are:





Reduces the need to fax
No additional cost
Access almost anywhere
Comprehensive view of UM requests
Easy access via Availity (Your PAA can grant you access to
Authorizations and you can start right away)
Interactive Care Reviewer (cont.)
Additional webinar training is available to learn more
about the features and benefits. Go to:
 https://www144.livemeeting.com/lrs/1100001891/
Registration.aspx?pageName=83vbvn5cvr00ngx4
Future planned enhancements include:
 Expand the use to incorporate behavioral health
and additional procedures.
Self Service Tools
E-Review
• Secured email tool that can be used for Inpatient, Outpatient
precertification and predetermination for local Anthem members.
Imaging and Specialty Rx-Web Tools
• Real time preauthorization's for Radiology, Echocardiography,
Radiation Oncology, Specialty Pharmacy, Sleep Study.
Medical Policy and Preauthorization Routing Tool
• This tool will allow providers to access the medical policies and
preauthorization information for other blue plans.

BlueCard members –out-of-area members
Steps to access the routing tool.
Step 1: Locate the blue Medical Policy, Clinical UM
Guidelines and Pre-Cert Requirements box on the left
side of the page and click “Enter”.
40
Steps to access the routing tool.
•Step 2: Click on the
appropriate link to
access the information
that is needed.
•The first two links are
for local Anthem
members. The bottom
two links are for
BlueCard out-of area
members.
41
How to use the tool.
Step 3: Select the type of information requested, enter the first
three letters of member’s identification number located on the
ID card in the alpha prefix box and click “GO”.
42
How to use the tool.
Step 4: Review the disclaimer stating that the user will be
leaving Anthem’s site and being directed to an external site not
affiliated with Anthem and click “Continue”. This disclaimer will
only appear for BlueCard inquiries.
43
It Worked!
1.
It worked! The user has been routed to Blue Cross Blue Shield of Illinois’s Medical Policy web page
2.
Here the user can view all medical policies for BCBSIL.
3.
Please note that most Blue plans have search function capability that will allow the user to search for
a specific procedure by name or code.
44
Self Service Tools
Secure Messaging
•Online secure messaging tool used to contact the PSU regarding
a claim
Local claim, BlueCard, FEP
Communications
•E-Updates
•Network News
Provider Maintenance Form (Under the [email protected] Tab)
•Electronic Form Required to Begin the Credentialing Process
•Add/Delete Providers or Products
•Make Any Demographic Changes (Address, Phone, Email, Fax)
Self Service Tools
Additional Tools:
• Quick Contact Sheet
• Network Relations Consultant Territory Listing
• Clinical Data Submission Tools
• Provider Adjustment Form
• Medical Policy/Clinical UM Guidelines
• Clinical Edits
• Product and Benefit information
• Appeals Process
• Provider Manual
Self Service Tools
Availity
Secure web portal that offers one easy place to
take care of administrative, clinical and
financial health plan tasks-one site for your
transactions with multiple health plan.
•Eligibility
•Benefits
•Claims
•Patient Care Summary
•Care Reminders
•Interactive Care Reviewer
•Imaging and Specialty RX
•Secure Messaging
•Member Certificates
•Payer Resources Tab
•Click Wrap Registration
Question and Answer
In most of Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name for RightCHOICE® Managed Care, Inc. (RIT),
Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO
benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits.
Independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark. The Blue Cross and Blue Shield names and symbols are
registered marks of the Blue Cross and Blue Shield Association.
Download
Related flashcards
Create Flashcards