Anthem Insurance Updates
Anthem Billing Issues
(Originally sent to members April 2019 – however this issue is resurfacing!) Anthem Billing Issues: Some providers have reported experiencing denials related to diagnosis codes when billing to Anthem. Upon review, these denials are related to codes that have an “Excludes 1” relationship with another code that is being used. You cannot bill two codes together if they have an “Excludes 1” notation.
Q: Why would codes be listed as “Excludes1”?
A: There are two scenarios by which this can happen:
- A condition can be congenital or acquired, but not both; it would not be appropriate to use a congenital and acquired code to diagnosis the same condition.
- When codes are considered mutually exclusive of one another, or a less specific code is included within a more specific code.
For example, -algia codes have exclusions that may overlap with other frequently used diagnoses.
Example 1:
M54.2 – Cervicalgia
Excludes1: cervicalgia due to intervertebral cervical disc disorder (M50.-)
Example 2:
M54.5 – Low back pain
Loin pain
Lumbago NOS
Excludes1:
low back strain (S39.012)
lumbago due to intervertebral disc displacement (M51.2-)
lumbago with sciatica (M54.4-)
Example 3:
M54.30 – Sciatica, unspecified side
Excludes1:
lesion of sciatic nerve (G57.0)
sciatica due to intervertebral disc disorder (M51.1-)
sciatica with lumbago (M54.4-)
“An “Excludes1” note indicates codes that should not be used at the same time as the code located directly above the “Excludes1” notation.” 2019 ICD10
These are examples of exclusions that may be frequently seen in a chiropractic office but is not exhaustive of all “Excludes1” scenarios you may experience. It is important to note, this is not a policy specific to Anthem, it just appears that their billing and coding software is now programmed to recognize the exclusions and deny the claim accordingly.
To verify exclusions that may exist with codes you use in your office, you can reference your most recent ICD-10 Chirocode book, or you can call or email the OSCA office with further questions.
Anthem Re-Exam Denial Appeal Template
Anthem previously announced that it would relaunch its prior authorization process for commercial plans specific to PT/OT/ST services, effective 11/1/19. This requirement affects 13 states including Ohio. While it states the requirements are specific to PT/OT/SP, it is important to know that they are referring to services and not providers.
Therefore, if you are a provider of physiotherapy services, active or passive, this requirement will affect you.
What do you need to do? Visit https://aimspecialtyhealth.com/providerportal/ to register.
This provider portal is now active for registration for Ohio Providers. https://aimproviders.com/rehabilitation/resources/
Is registration required at AIM Provider Portal
Each member of your staff who enters review requests will need to register. Here’s how to do it:
- Step one: Go to www.providerportal.com and select “Register Now” to launch the registration wizard
- Step two: Enter user details and select user role as “Ordering Provider”
- Step three: Create user name and password
- Step four: Enter the tax ID numbers for your providers
- Step five: Check your inbox for an email from AIM. Click on the link to confirm email address
The AIM ProviderPortal support team will then contact the user to finalize the registration process
What do I need to register?
- Your email address
- The tax ID number for the providers whose orders you will be entering
- Your phone and fax number
Link to AIM Rehabilitation Program FAQ:
https://aimproviders.com/rehabilitation/wp-content/uploads/sites/21/2019/10/Rehab_Pvdr_FAQs.pdf
The OSCA has been working with Anthem to understand this new requirement and to convey the burden that prior authorization creates for providers of conservative, non-pharmacological treatment options. As Anthem is moving forward with this requirement, the OSCA will be working with other impacted health care providers and state associations with the goal of reducing and removing these barriers to conservative care.
Anthem Q&A (sent 11/5/19)
Anthem Q&A (sent 11/5/19)
Q: I’m registering for the Provider portal and I’m not sure which health plan to select
Answer: You will select Anthem CR
Q: I’ve attempted a PA request and I don’t know what the response means?
Answer: There are 2 Responses that you may receive that indicate a PA is not required:
- Based on the search criteria you have entered, the member you are looking for is not part of our database. An order request cannot be processed for this member at this time. (Please modify your search criteria and try again, or contact the telephone number on the back of the member’s ID card.)
- Based on the service date entered, an AIM Order Number cannot be given for this member at this time. (Please contact the member’s health plan if you have any additional questions.)
**IMPORTANT**
1 and 2 above indicate that the member’s plan do not require PA. You do not have to call customer service for additional attempts to PA.
It is highly recommended to print this page or screenshot and save the response that you are given in the patient’s medical record.
Q: I am an out of network provider for Anthem. Am I required to complete the PA process?
Answer: Out of network providers are not required to comply with this requirement. If the patient has out of network benefits, they will apply accordingly.
Q: Who is having to perform these prior authorization requests?
Answer: Effective November 1, 2019, all in-network providers of PT, OT and ST services in the following states: CT, ME, NH, NY, GA, IN, KY, MO, OH, WI. In Q1 2020, CA, CO, NV will be included in the requirement.
Q: How does Anthem notify providers of these types of changes?
Answer: In the provider eNews Bulletin – https://providernews.anthem.com/ohio
Anthem Update (5/9/19)
- Anthem published two updates for E/M services, one with an effective date of 3/1/19, and a duplicate with an effective date 5/1/19. Anthem tells us they intended for one to apply to their Medicare Advantage plan and one to apply to their commercial plans, although that was not clear in their original publications.
- When our providers are reaching out to their Anthem Provider Representative to get clarification on the policy, they are given confusing or conflicting information. We have brought this to Anthem’s attention. We believe that some of the confusion is because they are crossing over information between the Medicare Advantage and Commercial plans.
- Anthem is meeting internally to review the information presented by OSCA and we anticipate a follow up meeting between OSCA and Anthem Ohio’s Medical Director and Provider Team.
Anthem E/M Update (4/9/19)
Anthem has provided an update, sent to all providers, regarding E/M services provided on the same day as a procedure or service.
The Anthem updates states:
“Anthem Blue Cross and Blue Shield (Anthem) has identified that providers often bill a duplicate Evaluation and Management (E/M) service on the same day as a procedure even when the same provider (or a provider with the same specialty within the same group TIN) recently billed a service or procedure which included an E/M for the same or similar diagnosis. The use of modifier 25 to support separate payment of this duplicate service is not consistent with correct coding or Anthem’s policy on use of modifier 25.
Beginning with claims processed on or after May 1, 2019 Anthem may deny the E/M service with a modifier 25 billed on the day of a related procedure when there is a recent service or procedure for the same or similar diagnosis on record.
If you believe a claim should be reprocessed because there are medical records for related visits that demonstrate an unrelated, significant and separately identifiable E/M service, please submit those medical records for consideration.”
The OSCA would like it’s members to be aware that you may send documentation to support that the exam was separate and should be reimbursed separately.
In response to this policy, the OSCA provided feedback to Anthem that Initial and Follow up E/M services should be covered, even when provided on the same day as a service. We have yet to receive a response, but will continue to update members as they become avaialble.
If you have any further questions, please contact the OSCA office.
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