A claim is the uniform bill form or electronic submission form in the format prescribed by Anthem and submitted for payment by a Provider for covered services rendered to an Anthem member. Any service rendered by a Provider and for which a Provider is reimbursed the lesser of billed charges or the amount dictated by the Anthem fee schedule is considered a claim.
We encourage you to submit claims electronically. Electronic claims submission is fast, accurate and reliable. Electronic claims may be submitted 24 hours a day, seven days a week. If complete information is provided, they will typically be processed seven to 10 days faster than paper claims. Please see the Electronic Claims Submission
subsection in this section of the manual for more information. Also visit our web site at: www.anthem.com/edi
then click on Colorado
as your state. You will find information on EDI transactions.
If submitting claims electronically is not a viable alternative, claims must be submitted on the CMS 1500 (08/05) Claim Form for non-facility services and on the UB 04 Claim Form for services provided in a facility. To be considered a clean claim, the following information is MANDATORY, as defined by the Colorado Division of Insurance, for each claim:
| The following fields of the Centers for Medicare & Medicaid Services (CMS) 1500 Claim Form must be completed before a claim can be considered a “clean claim:”|
Field 1: type of claim
Field 1a: insured identification number
Field 2: patient name
Field 3: patient birthdate/sex
Field 4: insured name
Field 5: patient address
Field 6: relationship of patient to insured
Field 7: insured address (if same as patient address; may indicate “same”)
Field 8: patient status (required only if patient is a dependent)
Field 9: other insurance (only if 11d is answered in the affirmative)
Field 10a, b, c: relation of condition to employment or auto accident
Field 11: policy number (this is situational in IG)
Field 11c: name of plan (this is situational in IG)
Field 11d: other insurance (if applicable)
Field 12: information release (“signature on file” is acceptable)
Field 13: assignment of benefits
Field 14: date of onset of illness or condition
Field 17: name of referring physician (if applicable)
Field 17a: NPI # of referring provider (situational)
Field 19- qualifier “ZZ” followed by Provider Taxonomy Code (Billing or Rendering Provider) Optional entry
Field 21: diagnosis
Field 23: prior authorization number (if any)
Field 24: A, B, C, D, E, F, G, H, I services and diagnoses
Field 24j: NPI # of rendering/performing provider
Field 25: federal tax ID number
Field 28: total charge
Field 31: signature of provider (provider name sufficient)
Field 32: address of facility where services were rendered (not required for EDI)
Field 32b: NPI # for Facility location for where services were rendered
Field 33: provider’s billing information
Field 33b: NPI for the Billing/Pay to provider
| The following fields of the UB04 Claim Form must be completed for a claim to be considered a “clean claim:” |
Field 1: provider name, address, telephone number (not required for EDI)
Field 3: patient number
Field 4: type of bill code
Field 5: provider tax ID number
Field 6: dates of claim period
Fields 7-10: inpatient hospital days, as appropriate
Field 12: patient name
Field 13: patient address
Field 14: patient date of birth
Field 15: patient sex
Field 16: marital status (not used in EDI)
Field 17: date of admission
Field 18: hour of admission
Field 19: type of admission
Field 20: admission source code
Field 21: discharge hour (for maternity only)
Field 22: patient status-at-discharge code
Fields 31-34: occurrence information (codes/dates )
Fields 35-36: occurrence information
Field 38: insured address (if same as patient, enter “same”)
Fields 39-41: value codes and amounts
Field 42: revenue code
Field 43: revenue description (not used in EDI)
Field 44: HCPCS/rates
Field 45: service date (for outpatient services only)
Field 46: service units
Field 47: total charges
Field 50: payer information
Field 52: information release
Field 53: assignment of benefits
Field 54 a-c Prior payments from primary, secondary or tertiary Insurances
Field 55 a-c Estimated amounts due from primary, secondary or tertiary
Field 58: insured name
Field 59: relationship of patient to insured
Field 60: a-c: patient /insured’s unique identification number
Field 62: group number (only if group coverage)
Field 63: prior authorization number (if any)
Fields 64 a-c: Document control number
Field 66: employer information (for workers’ compensation claims only)
Field 66 DX: Diagnosis version qualifier
Field 67: a-q: principal diagnosis code and additional diagnosis
Field 69: Admitting Diagnosis Code
Field 70 a-c: Patients reason for visit
Field 71: PPS Code
Field 76: admission diagnosis (inpatient only)
Field 79: required only if fields 80-81 are completed
Fields 80: multiple procedures (if applicable)
Field 80: Field for any additional remarks a provider may need to make
Field 81 a-d: qualifier “81” followed by Provider Taxonomy Code (Billing Provider) Optional entry
Field 82: attending physician ID
Fields 85-86: signature and date
Providers must bill with current CPT-IV or HCPCS codes. Codes that have been deleted from CPT-IV or HCPCS are not recognized. When a miscellaneous procedure code is billed or a code is used for a service not described in CPT-IV or HCPCS, supportive documentation must be submitted with the claim.
Only submit claims after service is rendered. Claims submitted without the above mandatory information are not accepted and will be returned to the Provider. In those cases, please fully complete and return the corrected claim with the Return to Provider Form within 30 calendar days for processing.
Accurate and complete claims can typically be processed more quickly than claims that require research. Claims denied
for incorrect or incomplete information must be resubmitted (with corrected information) on a Claim Action Request Form. Please resubmit the claim with a copy of the Anthem EOP showing the claim denial. Return the claim for processing within 30 calendar days of the denial notice. When submitting corrected information on a full
, partially paid
, or denied
claim, an adjustment
must be requested on a Claim Action Request Form, rather than submitting a new claim. When an unpaid
claim is returned to you with a cover letter stating that additional information is required for processing, please resubmit the corrected claim requested information (as appropriate) with a copy of the cover letter and a completed Claim Action Request Form
. Return the corrected claim or requested information for processing within 30 calendar days of the Anthem letter date. Please see the Claim Action Request Procedures
section of this Manual for more information.
Helpful Tips for Filing Claims
Other Insurance Coverage
When filing paper claims with other insurance coverage, please ensure the following fields are completed and that a copy of the explanation of benefits from the other insurance coverage is attached to the claim:
CMS 1500 Fields:
Field 9: other insured’s name
Field 9a: other insured’s policy or group number
Field 9b: other insured’s date of birth
Field 9c: employer’s name or school name (not required in EDI)
Field 9d: insurance plan name or program name (not required in EDI)
Field 50a: name of payer (secondary)
Field 50c: name of payer (if more than two)
Field 54a, 54b: prior payments (if applicable)
When filing claims for anesthesia services, minutes—must be billed. We’ll round the units upward, depending on the minutes billed. When multiple surgical procedures are done, only report the anesthesia code with the highest base value with the TOTAL time for all procedures. Multiple anesthesia codes will not be reimbursed. When billing surgery codes, only bill one unit of service as time is not considered. Surgical codes are reimbursed based on the RVU for the surgical procedure times the surgical conversion factor. Modifier AA should be reported in the 2nd position when other payment modifiers such as P3 are billed in order to assure additional allowance is added for the payment modifiers.
DME Rental Claims
Please do not submit claims until the rental period is completed. When itemizing sales tax as a separate billed charge, please use modifier RR with procedure code S9999. Note: This applies to paper claims only.
See the Medical Records Submission Guidelines
on the last page of this section. Note: This applies to paper claims only.
You must use modifier 99 on claim lines with multiple modifiers in the first position so all modifiers are considered for claims processing. Modifier 99 will cause a claim to pend so all modifiers can be considered for processing.
For more information, please see the Claims Editing Software Programs
portion of this section and the Additional Edits section on the secure provider website.
Late charges for claims previously filed can be submitted electronically. You must reference the original claim number in the re-billed electronic claim. If attachments are required, please submit them on paper with the completed Claim Action Request Form.
For an original billing, don’t itemize credit dollar amounts on the claim, because the total billed amount for each line must equal the total charges for the claim. If the original services were over-billed, please submit the correction on the Claim Action Request Form.
When filing claims for procedures with negative charges, please don’t include these lines on the claim. Negative charges often result in an out-of-balance claim that must be returned to the Provider for additional clarification.
Ambulatory Surgical Centers
When billing revenue codes, always include the CPT or HCPCS code for the surgery being performed. This code is needed to determine the procedure, and including it on the claim helps us process the claim correctly and more quickly.
When billing surgical revenue codes, include the appropriate CPT or HCPCS code.
Date of Current Illness, Injury or Pregnancy
For any 800-900 diagnosis code, an injury date is required. For a pregnancy diagnosis, the date of the member’s last menstrual cycle is required to determine a pre-existing condition.
Type of Billing Codes
When billing facility claims, please make sure the type of bill coincides with the revenue code(s) billed on the claim. For example, if billing an outpatient revenue code, the type of bill must be for outpatient services.
When billing facility claims, please make sure the surgery date is within the statement from and to dates on the claim. Claims that include a surgical procedure date that falls outside the statement from and to dates will be returned to the Provider.
Present on Admission (POA)
This section applies to acute care inpatient hospital claims with bill types of 11X or 12X.
The following hospitals are EXEMPT from the POA indicator requirement:
| Critical Access Hospitals (CAHs)|
| Long-Term Care Hospitals (LTCHs)|
| Maryland Waiver Hospitals|
| Cancer Hospitals|
| Children's Inpatient Facilities|
| Inpatient Rehabilitation Facilities (IRFs)|
| Psychiatric Hospitals|
On the UB04, the POA indicator is the eighth digit of Field Locator (FL) 67, Principal Diagnosis, and the eight digit of each of the Secondary Diagnosis fields, FL 67 A-Q. Report the applicable POA indicator (Y, N, U, or W) for the principal and any secondary diagnoses and include this as the eighth digit; leave this field blank if the diagnosis is exempt from POA reporting. Claims submitted with an invalid POA indicator will be returned.
Y - Diagnosis was present at time of inpatient admission
N - Diagnosis was not present at time of inpatient admission
U - Documentation insufficient to determine if condition was present at the time of inpatient admission
W - Clinically undetermined. Provider unable to clinically determine whether the condition was present at the time of inpatient admission
1 - Exempt from POA reporting. This code is the equivalent code of a blank on the UB-04, however, it was determined that blanks were undesirable on Medicare claims when submitting this data via the 004010/00410A1
National Provider Identifier
The National Provider Identifier (NPI) is one provision of the Administrative Simplification section of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Anthem is accepting the NPI on Electronic and Paper transactions. Effective May 23, 2008, you must submit your NPI (as your only provider identifier) on your Electronic and/or Paper transactions.
Anthem NPI Online Submission Process has been retired.
, Provider groups or facilities with subparts:
For information on obtaining the NPI, you may visit the CMS website at http://www.cms.hhs.gov/NationalProvIdentStand/03_apply.asp
Location of the NPI on Claims Forms
NPI location for electronic transactions:
| The NPI will be reported in the Provider loops on electronic transactions. The following elements are required:|
The NM108 qualifier will be “XX” for NPI submission.
The NM109 field will display the 10-digit NPI.
The TIN will be required in the Ref segment when the NPI is reported in the NM109.
The REF01 qualifiers (EI = TIN; SY = Social Security number)
The REF02 field will display the Provider’s or facility’s TIN or Social Security number.
| The chart below outlines the changes for 837 professional, institutional and dental claims:|
Primary Identifier Qualifier
Key “XX” for NPI submission.
Key the 10-digit NPI. (The tax ID number will be required in the Ref segment when the NPI is reported in the NM109 locator.) This requirement of TaxID will be on Billing, Payto, and rendering Provider loops only
Secondary Identifier Qualifier
Key “EI” (tax identification) or “SY” (Social Security number).
Key the Provider tax ID number or Social Security number.
NPI location on the electronic remittance advice (835):
Loop 1000B; N103
Loop 1000B; N104
Loop 1000B; REF01
Loop 1000B; REF02
Loop 2000; TS301
Loop 2100; NM108
Loop 2100; NM109
NPI location on paper forms:
| Revised CMS 1500 (08/05) (NUBC)|
The NPI will be displayed in box/field 17b for the referring Provider.
The NPI will be displayed in box/field 24j for the rendering Provider.
Locators 32a and 33a are also designated for the NPI for the servicing Provider locations and Pay to/billing Provider location.
NPI location on paper forms:
| UB04 (NUBC)|
The NPI will be displayed in the following boxes/fields:
Box/field 56 for the facility
Box/field 76 for the attending physician
Box/field 77 for the operating physician
Box/fields 78 and 79 for other provider type
Claims must be submitted within the timely filing timeframe specified in your contract. Anthem only accepts one member and one Provider per claim.
All additional information reasonably required by Anthem to verify and confirm the services and charges must be provided on request. The Provider must complete and return requests for additional information within 30 calendar days of Anthem’s request.
Claims submitted after the timely filing period expires will be denied, unless proof of timely filing can be demonstrated according to the guideline listed below.
Proof of Timely Filing
Waiver of the timely filing requirement is only permitted when Anthem has received convincing documentation indicating the member or Provider originally submitted the claim within the applicable timely filing period.*
The documentation submitted must indicate the claim was originally submitted before the timely filing period expired.
Acceptable documentation includes the following:
| A copy of the claim with a computer-printed date (a handwritten date isn’t acceptable)|
| An original fax confirmation specifying the claim in question and including the following information: date of service, amount billed, member name, original date filed with Anthem or dates billed to the member, and description of the service|
| The Provider’s billing system printout showing the following information: date of service, amount billed, member name, original date filed with Anthem or dates billed to the member, and description of the service|
If the Provider doesn’t have an electronic billing system, approved documentation is a copy of the member’s chart indicating the billed date and/or a copy of the billing records indicating the billed date, and the information listed above.
| If the claim was originally filed electronically, a copy of Anthem’s electronic acceptance/rejection report is required; a copy can be obtained from the Provider’s EDI vendor, EDI representative or clearinghouse representative. The Provider also must demonstrate that the claim and the member’s name are on the original acceptance/rejection report. |
| A copy of the Anthem letter requesting additional claim information showing that date information was requested.|
If the Provider originally received incorrect insurance information, the Provider has 30 calendar days from the date the Provider is advised of the correct insurance information to file the claim with the correct carrier.
Appeals for claims denied for failing to meet timely filing requirements must be submitted to Anthem in writing. Anthem doesn’t accept appeals over the phone.
Any exceptions to the proof of timely filing policy require the signature of the person in the director-level position or above in the applicable Anthem department.
* Timely filing requirements are as stated in the Provider Agreement for Provider-submitted claims and as stated in the member certificate for member-submitted claims.
Please send all claims data to the applicable address listed in the Telephone/Address Directory
Electronic Claims Submission
What Is EDI?
Electronic Data Interchange (EDI) is the computer-to-computer exchange of business documents in a structured, mutually agreed upon data format. EDI provides a cleaner and more expedient method for delivering time-dependent data. In contrast, paper claims must be printed, prepared for mailing, and eventually delivered by courier or through the mail, becoming vulnerable to multiple failure points. EDI claims have an exact audit trail that can be traced from submission to payment.
The benefits of electronic claims submission include the following:
| Reduced claim expenses ($2.00+ per claim savings on average)|
| Reduced rejections|
| Improved audit trails|
| Faster claims payment/adjudication (on average, payment for a “clean” claim is received within 14 business days)|
| Electronic reports|
| 24-hour file submission|
To submit claims electronically, senders use standard dial-up modems, NDM or FTP protocol to access Anthem’s EDI system. Once received, the claim is validated for format, content and completeness. When errors are detected, the sender is electronically notified via a Level 2 acceptance/rejection report.
If you’re currently unable to submit your claims electronically, please call the EDI Solutions Help Desk at 800-332-7575, or go to www.anthem.com/edi
to learn about your options. For more information, click Claims Submission Options on the EDI page.
Anthem accepts ANSIX12 4010A1837 P (professional) claims and ANSIX12 4010A1837 I (institutional) claims electronically.
Additional information about HIPAA compliance is available at www.edi.anthem.com
Anthem supports the following HIPAA transaction code sets:
| 837I – Institutional claims|
| 837P – Professional claims|
| 837D – Dental claims|
| 837 – Coordination of benefits (COB) or secondary claims|
| 270/271 – Eligibility requests and eligibility responses|
| 276/277 – Claims status requests and claims status responses|
| 835 – Electronic remittance advice|
| 278 – Authorizations|
| 997 – Functional acknowledgement|
| 834 – Enrollment (group only)|
| 820 – Electronic premium payment (group only)|
| EFT – Electronic Funds Transfer|
Note: Claim adjustments not requiring paper attachments, including late charges, and secondary claims may be submitted electronically. If you have questions about how to submit them electronically, please call the EDI Solutions Help Desk at 800-332-7575.
Transactions for future development:
| 275 – Claims attachments|
Some claims requiring attachments may be sent. For more information, please see the Attachments
section of the EDI website, or call the EDI Solutions Help Desk.
For support with electronic claims submission, please contact EDI Solutions Help Desk:
| Toll free: 800-332-7575 |Note:
For EDI registration forms, companion documents, and other information about EDI, please go to www.edi.anthem.com
Note: Currently, we don’t accept electronic claims for the Guest Membership program. You must submit those claims as paper claims.
Explanation of Benefits (EOB) and Remittance Advice (RA)
The explanation of benefits (EOB) or Remittance Advice (RA) will include the information needed to post claims for each member included during this processing cycle. Anthem will send one check to cover the total amount on the EOB/RA. To receive your EOBs/RAs electronically, please call 800-332-7575, or download the 835 registration form at www.anthem.com/edi
EOBs and remittance advice (RA) will now be in the same format for all local and BlueCard® members
Claims Editing Software Programs
Anthem uses ClaimCheck®
on our claims processing systems. ClaimCheck®
is used to evaluate the accuracy of medical claims and their adherence to accepted CPT/HCPCS coding practices. American Medical Association, CPT Assistant, recommendations from specialty societies, the Centers for Medicare & Medicaid Services, and other standard-setting organizations for claims billing procedures are considered in developing Anthem’s coding and reimbursement edits and policies. Claims editing software is sometimes used to support Anthem’s reimbursement policies. (The list of reimbursement policies is posted in our provider portal, ProviderAccess. If you are not currently registered, see the Customer Service and ProvideAccess section for further details).
These claims editing systems allow us to monitor the increasingly complex developments in medical technology and procedure coding used to process physician payments. ClaimCheck performs the following types of edits:
| Procedure unbundling occurs when two or more procedures are used to describe a service when a single, more comprehensive procedure exists that more accurately describes the complete service performed by a Provider. In this instance, the two codes may be replaced with the more appropriate code by our bundling system.|
| An incidental procedure is performed at the same time as a more complex primary procedure. The incidental procedure doesn’t require significant additional physician resources and/or is clinically integral to the performance of the primary procedure. |
| Mutually exclusive procedures are two or more procedures usually not performed during the same patient encounter on the same date of service. Mutually exclusive rules may also govern different procedure code descriptions for the same type of procedure for which the physician should be submitting only one procedure.|
| Duplicate procedure editing involves duplicate procedures submitted with the same date of service. Duplicate procedures include the following:|
When the description of the procedure contains the word “bilateral,” the procedure may be performed only once on a single date of service.
When the description of a procedure code contains the phrase “unilateral/bilateral,” the procedure may be performed only once on a single date of service.
When the description of the procedure specifies “unilateral” and there is another procedure whose description specifies “bilateral” performance of the same procedure, the unilateral procedure may not be submitted more than once on a single date of service.
When the description of one procedure specifies a “single” procedure and the description of a second procedure specifies “multiple” procedures, the single procedure may not be submitted more than once on a single date of service.
The global duplicate value is the total number of times it’s clinically possible or medically necessary to perform a given procedure on a single date of service across all anatomic sites.
Site-specific auditing logic uses modifiers to determine if the procedure being audited was performed on a different body site. When a modifier indicates that a procedure was performed on a different site, site-specific auditing logic will then determine whether this difference in sites warrants an override of the edit, with potential separate reimbursement recommended for both procedures.
The following site-specific modifiers are used:
UPPER LEFT, EYELID
LOWER LEFT, EYELID
UPPER RIGHT, EYELID
LOWER RIGHT, EYELID
LEFT HAND, THUMB
LEFT HAND, SECOND DIGIT
LEFT HAND, THIRD DIGIT
LEFT HAND, FOURTH DIGIT
LEFT HAND, FIFTH DIGIT
RIGHT HAND, THUMB
RIGHT HAND, SECOND DIGIT
RIGHT HAND, THIRD DIGIT
RIGHT HAND, FOURTH DIGIT
RIGHT HAND, FIFTH DIGIT
RIGHT CORONARY ARTERY
LEFT CIRCUMFLEX CORONARY ARTERY
LEFT ANTERIOR DESCENDING CORONARY ARTERY
LEFT FOOT, GREAT TOE
LEFT FOOT, SECOND DIGIT
LEFT FOOT, THIRD DIGIT
LEFT FOOT, FOURTH DIGIT
LEFT FOOT, FIFTH DIGIT
RIGHT FOOT, GREAT TOE
RIGHT FOOT, SECOND DIGIT
RIGHT FOOT, THIRD DIGIT
RIGHT FOOT, FOURTH DIGIT
RIGHT FOOT, FIFTH DIGIT
In certain circumstances, it’s appropriate to use modifiers to report services that warrant reimbursement separately from what would usually be expected. The use of these modifiers, listed below shouldn’t be routine but instead reserved for special circumstances prompted by an individual situation involving a patient. For more information about using modifier 25 and exceptions to recognition of modifiers 25 and 59 processing guidelines, please go to anthem.com, log in to Provider Inquiry under Answers@Anthem, and see “Modifier 25 & 59 Rules” under Claims Processing Rules.
| Modifier 25 is used to indicate that on the day a procedure or preventive exam was performed, the patient’s condition required a significant, separately identifiable evaluation and management (E&M) service beyond the usual care associated with the procedure or preventive exam. Without the modifier-25 designation, the E&M code is bundled into the procedure, or preventive exam. Only append modifier 25 to evaluation and management codes 99201-99499. Routine use of modifier 25 to avoid bundling edits is inappropriate. Only use it for unique situations as indicated above. If modifier 25 is appended to inappropriate codes, it will be disregarded. To expedite processing of adjustments to add modifier 25 when it wasn’t originally billed, supporting documentation is required. Documentation isn’t required when using modifier 25 on the initial claim. For more information on Modifier 25 please refer to Anthems reimbursement policy RE.022.Modifier 25.|
| Modifier 57 is used to identify the patient encounter that resulted in the decision to perform surgery. Without the modifier, the E&M code is bundled to the surgical procedure when performed the day of or the day before a major surgical procedure.|
| Modifier 59 is used to identify procedures/services that aren’t normally reported together but are appropriate under the circumstances. This may include a different procedure or surgery, a different site, or a separate incision/excision, lesion or patient encounter. Without the modifier 59 designation, bundling may occur. Only append modifier 59 to procedures or surgeries. It’s not appropriate for supplies, other DME codes, or E&M codes. If modifier 59 is appended to inappropriate codes, it will be disregarded. Routine use of modifier 59 to avoid bundling edits is inappropriate. Only use it in unique situations as indicated above. For more information on Modifier 59 please refer to Anthems reimbursement policy RE.017.Modifier 59.|
| Multiple modifiers: Modifier 99 is used to identify multiply modifiers. Multiple modifiers are sometimes needed to describe a particular code. On a claim line with multiple modifiers that could affect pricing, append modifier 99 in the first modifier position. Our systems only adjudicate the first modifier on the claim line. Appending modifier 99 in the first modifier position will cause the claim to pend so that it can be manually adjudicated with all modifiers billed.|
| Modifier 50 is used to indicate a bilateral procedure. Effective November 1, 2007, we will be following CMS guidelines when processing bilateral surgeries/procedures. When a procedure is not identified by its terminology as a bilateral procedure it is billed on one line with the surgical procedure code and modifier 50. Bilateral surgeries/procedures are considered one surgery. The allowable amount is calculated by multiplying 150% of the unit value times the conversion factor. If the code is reported as a bilateral procedure, and is reported with other procedure codes on the same day, then the bilateral adjustment will be applied before applying any multiple procedure rules. This update of bilateral surgeries/procedures billed with (modifier 50) may impact how the multiple surgery reduction is calculated. And, the relative value unit (RVU) on the bilateral procedure may increase now that it will be reimbursed as one procedure causing it to become the primary procedure. For more information about Modifier 50 processing please refer to Anthem Colorado and Nevada Reimbursement Policy RE. 013 Multiple and Bilateral surgery. The notification letter explaining the processing of Modifier 50 is also located on the provider website.|
| Age edits occur when the Provider assigns an age-specific procedure or diagnosis code to a patient whose age is outside the designated age range. |
| Gender edits occur when the Provider assigns a gender-specific procedure or diagnosis code to a patient of the opposite sex. |
| Frequency edits occur when a procedure is billed more often than would be expected. Frequency edits occur when:|
| Repeat consultations are billed by the same Provider on the same patient more frequently than every six months.|
| Base procedure codes are billed with a quantity greater than one on a single date of service.|
| Procedures whose description includes a numeric definition or the term “single,” “one or more” or “multiple” are billed with a quantity greater than one on a single date of service.|
| Obstetrical epidural anesthesia edits occur when the reported anesthesia time exceeds 2.5 hours. A maximum of 2.5 hours of anesthesia time is routinely allowed. Upon review, additional time units may be allowed with documentation that face-to-face time with the obstetrical patient exceeded 2.5 hours. For more information on OB anesthesia please refer to Anthem’s reimbursement policy, RE.005 Anesthesia for Labor and Delivery.|
Bundled service edits occur when a procedure code with a Status B, or T indicator, on the Resource Based Relative Value Scale (RBRVS) is billed on the same date as any other procedure. Status B codes are reimbursed only when no other services are provided on the same day. This includes surgical trays (code A4550). Please refer to Anthems reimbursement policy RE.006 Always Bundles Services.
In some cases, modifiers may be added or codes may be changed to help ensure correct claims payment.
ClaimCheck® is a registered trademark of McKesson HBOC.
Clear Claim ConnectionTM
Clear Claim Connection (CCC) is an online tool available through Anthem’s provider portal, ProviderAccess, that is intended as a tool for evaluating clinical coding information. CCC will provide information according to the claim editing system logic on the date of the provider’s inquiry, and allows providers to view clinically-based information along with documented source information for approximately two million edits. CCC is not a guarantee of member eligibility or claim payment, and is not date-sensitive for the claim date of service.
Sources referenced for the CCC online tool include: American Medical Association Current Procedural Terminology (CPT), CPT Assistant, CPT Coding Symposium, Specialty Society Coding Guidelines and Medicare Guidelines. Not all national accounts, FEP or Medicare Advantage products utilize the claim editing system logic used in Clear Claim Connection, and not all procedure modifiers impact the pricing or processing of procedures (based on Anthem policy).
To access the Clear Claim Connection online tool, go to anthem.com, select Provider and Colorado. From the Provider Home page login to ProviderAccess. Select the Claims tab, and then the Clear Claim Connection link.
Clear Claim ConnectionTM is a trademark of McKesson.
Coordination of Benefits and Subrogation
Coordination of benefits (COB) refers to the process for members receiving full benefits while preventing double payment for services when a member has coverage from two or more sources. The member’s contract outlines which entity has primary responsibility for payment and which entity has secondary responsibility for payment.
Providers shall establish procedures for identifying members who have work-related injuries or illnesses or who have other coverage, including auto insurance, that may be coordinated with Anthem coverage. Providers shall use their best efforts to notify Anthem whenever they have reason to believe a member may be entitled to coverage under any other insurance plan, including Medicare, and shall assist Anthem in obtaining COB information when a member holds such other coverage.
Providers agree to make their best effort to identify and notify Anthem of any facts that may be related to auto, workers’ compensation, or third-party injury or illness, and to execute and provide documents that may reasonably be required or appropriate for the purpose of pursuing reimbursement or payment from other payers.
Coordination of Benefits for BlueCard®
If, after calling 800-676-BLUE or through other means you discover that a member’s insurance plan contains a COB provision, and if any Blue Cross and/or Blue Shield plan is the primary payer, please submit the claim(s) along with information about COB to Anthem. If COB information isn’t included with the claim, the member’s plan or the insurance carrier will have to investigate the claim, which will delay claim processing.
Anthem adjudicates COB claims according to the following guidelines:
| When Anthem is the primary carrier, standard Anthem reimbursement, along with applicable copayments, coinsurance and deductibles, is considered payment in full from Anthem.|
| If Medicare is the primary payer, Anthem will use the Medicare allowed amount or the limiting amount (if the Provider didn’t accept Medicare assignment) to determine a secondary payment.|
| For PPO and Indemnity claims when Anthem is the secondary carrier and the primary carrier isn’t Medicare, the higher of either Anthem’s or the primary carrier’s allowance will be used to determine a secondary payment.|
| For HMO claims when HMO Colorado is the secondary carrier and:|
HMO Colorado’s reimbursement is capitation: The Provider has already received payment from HMO Colorado, and this payment fulfills HMO Colorado’s obligations as a secondary carrier. This payment shall be used to cover the member’s obligations under the member’s primary coverage, including any copayment or other liabilities. Therefore, the Provider may not charge the member for any copayment or other liability; if funds are collected from the member, the Provider must reimburse the member for those charges from the Provider’s capitation payment.
HMO Colorado’s reimbursement is non-capitated, i.e., some form of fee-for-service: When the primary carrier is not Medicare, the higher of either HMO Colorado’s or the primary carrier’s allowance will be used to determine a secondary payment. At no time will HMO Colorado pay more as the secondary carrier than it would have paid in the absence of another insurance carrier.
Medicare is the primary payer: HMO Colorado will use the Medicare allowed amount or the limiting amount (if the Provider did not accept Medicare assignment) to determine a secondary payment.
| At no time will Anthem pay more as the secondary carrier than it would have paid had it been the primary carrier. |
Members with Individual Plan Coverage
Benefit payments for Anthem members with Individual coverage cannot be coordinated with another commercial health insurance carrier. However, benefits may be coordinated with workers’ compensation, Medicare coverage or third-party (subrogation), excluding a member’s auto medical payments. Before sending Anthem a refund due to duplicate claims payment, please verify that the refund being submitted is for a member with Group – not Individual – coverage
Situations When Clinical Information Is Required
The following claims categories may routinely require submission of clinical information before or after payment of a claim:
| Claims involving pre-certification/prior authorization/pre-determination or some other form of utilization review, including, but not limited to the following: |
Claims pending for lack of pre-certification or prior authorization
Claims involving medical necessity or experimental/investigational determinations
Claims for pharmaceuticals that require prior authorization
| Claims involving certain modifiers, including, but not limited to, modifier 22|
| Claims involving unlisted codes|
| Claims for which Anthem can’t determine, from the face of the claim, whether it involves a covered service and therefore can’t make the benefit determination without reviewing medical records (examples include, but aren’t limited to, pre-existing condition issues, emergency service-prudent layperson reviews and specific benefit exclusions) |
| Claims Anthem has reason to believe involve inappropriate (including fraudulent) billing |
| Claims, including high-dollar claims, that are the subject of an internal or external audit|
| Claims for members involved in case management or disease management|
| Claims that have been appealed or are otherwise the subject of a dispute, including claims being mediated, arbitrated or litigated|
| Other situations in which clinical information may routinely be requested:|
Requests related to underwriting, including, but not limited to, member or physician misrepresentation/fraud reviews and stop-loss coverage issues
Quality improvement/assurance activities
Coordination of benefits
Examples provided in each category are for illustrative purposes only and aren’t meant to represent an exhaustive list within the category.