Resource Based Relative Value Scale
Anthem’s fee schedule is based on the Centers for Medicare & Medicaid Services (CMS) Resource Based Relative Value Scale (RBRVS). A single conversion factor developed by and specific to Anthem is used for reimbursement purposes.
The RBRVS is based on the resources a physician typically uses for each procedure and service, from physical, intellectual and emotional effort to overhead and training. The following components are used in computing a fee for a given service:
| Physician work|
| Practice expense, including office rent, non-physician salaries, capital equipment costs and supplies|
| Professional liability (malpractice) expense, including the cost of professional liability insurance|
The RBRVS method doesn’t set unit values for anesthesiology and clinical laboratory procedures. In these instances, Anthem uses the American Society of Anesthesiologists (ASA) relative values for anesthesiology and modified Medicare fees for clinical lab.
Throughout this Manual, Anthem’s method of reimbursement will be referred to as the current Anthem fee schedule, which is a combination of the modified RBRVS values, the services not evaluated by RBRVS and the Anthem conversion factor.
Providers contracted with Anthem agree that in no event, including, but not limited to, non-payment by Anthem, Anthem insolvency or breach of the Provider Agreement, will the Provider bill, charge or collect a deposit from; seek compensation, remuneration or reimbursement from; or have any recourse against Anthem members or persons other than Anthem, acting on its own behalf, for services provided pursuant to the Provider Agreement. This provision will not prohibit collection of coinsurance, copayments or deductibles in accordance with the terms of the applicable member certificate or collection of payment for non-covered services, except as otherwise expressly prohibited by the Provider Agreement.
Providers contracted with Anthem agree that 1) this provision will survive the termination of the Provider Agreement regardless of the cause giving rise to termination and shall be construed to be for the benefit of the member, and 2) this provision supersedes any oral or written contrary agreement now existing or hereafter entered into between a Provider and any member or person acting on his or her own behalf.
On-Call Coverage For Primary Care Physicians
Primary care physicians (PCPs) are required to provide 24-hour coverage, seven days a week, for Anthem members. After-hours coverage may consist of the following:
| A covering physician who is a PCP in the member’s designated PCP’s clinic or medical management group, in which case a referral isn’t necessary|
| The covering physician is contracted with Anthem, and the covering physician’s name is in the Anthem system as an on-call Provider for the PCP. When an Anthem member sees an on-call Provider, claims are processed at the on-call Provider’s contracted rate with Anthem.|
Please forward updated on-call information, in writing, to the Provider File Management address listed in the Customer Service and ProviderAccess
section of this Manual.
Providers should collect copayments from members at the time services are rendered. Please refer to the member’s health plan ID card for copayment information.
Office Visit Copayments
An office copayment is required for most office visits for which a Provider’s office ordinarily generates a charge, including blood pressure checks, regularly scheduled injections and educational sessions with a nutritionist, physical therapist, etc. If a charge isn’t generated for a visit, the Provider doesn’t collect a copayment.
For HMO Colorado members only: Non-surgical diagnostic procedures for which there are no other associated office visit charges are the only services for which a Provider doesn’t collect an office visit copayment from an HMO Colorado member. Such services include lab work, X-rays, mammograms, audiograms, EKGs, etc. Immunizations and flu shots do not require a copayment if no other office visit charge is associated with these procedures.
Emergency/Urgent Care Copayment
The emergency care copayment is collected by the emergency room at an acute care hospital.
The urgent care copayment is collected by the PCP’s office when:
| The office must disrupt its schedule to see an Anthem member on an urgent care basis during the day; or|
| The physician sees the member after hours or during weekend hours when no facility fee is charged.|
The urgent care copayment is collected when a member is seen at an out-of-area urgent care center. These amounts are listed on the member’s health plan ID card. For HMO Colorado members only, the emergency and urgent care copayments most often are the same amount, although in some cases, the copayment amounts will be different.
Inpatient Hospital Copayment
The inpatient hospital copayment is paid to hospitals for inpatient admissions. Payment arrangements can be made between the hospital and the member before an inpatient hospital admission.
Emergency And Urgent Care Services
Emergency/Urgent Care Codes
Valid procedure codes must be used when medical services are rendered in the office or consult room of a hospital where no facility fee is charged rather than sending the member to the emergency room in an urgent or emergency situation outside normal office hours. (After-hours care/office services is defined as care requested outside a Provider’s normal or published office hours, such as between 10 p.m. and 8 a.m., or services requested when a Provider’s office is closed on weekends and holidays.)
These procedure codes should not be used for routine care that can wait until regular office hours. These codes only apply to emergency and urgent care. Benefits for routine or preventive care services provided in the emergency department are not within the meaning of emergency services.
The applicable deductible, coinsurance and/or copayment requirements for emergency services remain in place, and Anthem members are responsible for paying those cost-sharing amounts.
Overpayment Recovery Procedure
Anthem seeks recovery of all excess claim payments from the payee to whom the benefit check is made payable.
The procedure for overpayment recovery for participating Providers involves the following notifications to physicians, hospitals, facilities and other health care professionals:
Day 1: Anthem identifies overpayment.
Day 3: A letter is sent to the Provider requesting overpayment.
If the facility believes the overpayment was created in error, it should contact Anthem in writing. For a claims re-evaluation, send your correspondence to the address indicated on the overpayment notification.
* Send all payments with a copy of the overpayment letter to:
PO Box 92420
Cleveland, OH 44193
Note: Please reference claim number with all payments, not account number
If Anthem doesn’t hear from the facility or receive payment within 30 days, the following action is taken:
Day 30: A second letter is sent to the Provider. This is a final request for payment. The letter indicates that if Anthem doesn’t receive payment within 15 days, then the overpayment amount “recovery” is taken out of future claims payments.
Day 45: If Anthem doesn’t receive payment, the overpayment amount is deducted from claims payments.
Day 60: When Anthem determines that recovery isn’t feasible, a third letter is sent to the Provider.
Day 90: If Anthem doesn’t receive payment, a fourth letter is sent to the Provider.
Day 110: If Anthem doesn’t receive a check for the overpayment, the overpayment is referred to a collection service.
Important Information About the Federal Employees Health Benefits Program
The following information applies to members who:
| Aren’t covered by either Medicare Part A (hospital insurance) or Part B (medical insurance), or both.|
| Are enrolled in the Blue Cross and/or Blue Shield plan as an annuitant, or as a former spouse or family member covered by the family enrollment of an annuitant or former spouse.|
| Aren’t employed in a position that confers Federal Employees Health Benefit coverage.|
If the member isn’t covered by Medicare Part A, is age 65 or older and receives care in a Medicare-participating hospital, the law (5 U.S.C. 8904[b]) requires the Blue Cross and/or Blue Shield plan to base payment on an amount equivalent to the amount Medicare would have allowed if the member had Medicare Part A. This amount is called the equivalent Medicare amount. After the Blue Cross and/or Blue Shield plan pays, the law prohibits the hospital from charging the member more for covered services than any deductibles, coinsurance or copayment owed by the member under the Blue Cross and/or Blue Shield plan. Any coinsurance the member owes will be based on the equivalent Medicare amount, not the actual charge.
HMO Colorado Point-Of-Service Rider
HMO Colorado offers employer groups a point-of-service (POS) rider designed to complement BlueAdvantage HMO benefits. The POS rider is an “opt-out” product for members who want to receive covered health care services without guidance from a primary care physician (PCP) in the HMO Colorado network.
How the POS Rider Works
In-network (HMO benefits): A member must select a PCP. If the member follows HMO Colorado guidelines and sees only the selected PCP or seeks services from in-network specialists, the member receives the member’s BlueAdvantage HMO benefits, less any in-network copayments. Emergency benefits are provided through HMO Colorado if the member follows HMO Colorado procedures.
Out-of-network (POS benefits): A member can choose to receive health care services from an out-of-network provider. Certain services under the POS provision will be covered at a lower level than services received from the selected PCP or in-network specialists. This means members may have to pay an annual deductible, as well as coinsurance, for these services. The out-of-network provider’s reimbursement for POS services is based on HMO Colorado’s maximum benefit allowance, according to the member’s certificate. Certain services require pre-certification.
The following services are not covered benefits under HMO Colorado’s POS provisions when rendered by an out-of-network provider, but they may be covered under the HMO provisions when rendered by an in-network PCP or an in-network specialist:
| Ambulance services (except emergency ambulance services) |
| Infertility services|
| Behavioral health care services, except biologically based mental health services, i.e., for parity diagnoses (see the Behavioral Health and Chemical Dependency Rehabilitation Services section of this Manual for a listing of parity diagnosis codes) or autism, posttraumatic stress disorder, dysthymia, cyclothymia, social phobia, agoraphobia with panic disorder, general anxiety disorder, anorexia nervosa and bulimia nervosa |
| Preventive care services, except annual gynecological exams, and well-baby and well-child care up to age 13|
| Certain organ transplants|
HMO Colorado Away From Home Care Program
The Away from Home Care program is part of the BlueCard® program and provides certain benefits to eligible members who are traveling outside their Blue Cross and/or Blue Shield HMO Home Plan’s service area and staying in the service area of a participating Blue Cross and/or Blue Shield HMO Host Plan. The benefits provided under the Away from Home Care program are as follows:
| Emergency care for unexpected illness or injury that requires immediate medical care |
| Urgent care for unexpected illness or injury that isn’t life-threatening but that cannot reasonably be postponed until the member returns home. Urgent care includes follow-up to an initial urgent care visit.|
| Pre-certified follow-up care for an injury or illness that originated in the HMO Home Plan service area that requires medical care while the member is traveling away from home. This care is pre-arranged by the member with the member’s Home Plan before services are rendered. Follow-up care includes, but isn’t limited to, services such as allergy shots, high-blood-pressure checks and cast removal.|
Out-of-state Blue Cross and/or Blue Shield HMO plans have elected to use the BlueCard program to process urgent and follow-up care claims. Members of these plans will present their out-of-state member ID card at the time of service. These cards have a three-letter alpha prefix and a suitcase emblem that indicates their eligibility in the BlueCard program. Please collect any applicable copayments as listed on the member’s ID card, and submit claims to the BlueCard address in the Telephone/Address Directory section of this Manual. These claims will be processed and priced according to the Provider’s HMO Colorado contracted rates.
Local HMO Colorado member ID numbers will contain an XFF or XFY alpha prefix. Claims for HMO Colorado members are processed through the local HMO Colorado claims address listed in the Telephone/Address Directory section of this Manual and not through BlueCard.
The Guest Membership benefit of the Away from Home Care program provides courtesy membership for members who are temporarily residing outside their HMO Home Plan service area and who are enrolled in the HMO Colorado Guest Membership program. Members receive a courtesy enrollment from the HMO Colorado guest membership department and have access to a comprehensive range of benefits, including routine and preventive care services. Members must complete a Guest Services Application with their HMO Home Plan and then work with the HMO Colorado guest membership department to select a local PCP. The member pays any applicable copayments and deductibles to the Provider at the time of service, and HMO Colorado pays the Provider.
BlueCard® Member Eligibility
With the member’s current ID card in hand, Providers can verify membership and coverage by calling BlueCard® eligibility at the phone number in the Telephone/Address Directory
An operator will ask for the alpha prefix on the member’s ID card and will connect the Provider to the appropriate membership and coverage unit at the member’s Blue Cross and Blue Shield plan.
If you can’t locate an alpha prefix on the member’s ID card, check for a phone number on the back of the ID card. If that’s not available, call the Provider customer service phone number in the Telephone/Address Directory
section of this Manual and not
HMOSelect is a suite of lower-cost HMO health care benefits plans with a select network of Centura facilities and other key health care Providers in the seven-county Denver metro area, which includes Adams, Arapahoe, Boulder, Broomfield, Denver, Douglas and Jefferson counties, and the Colorado Springs area, which includes Elbert, El Paso and Teller counties. HMOSelect is offered by HMO Colorado, a subsidiary company of Anthem Blue Cross and Blue Shield..
HMOSelect includes coverage for preventive care, urgent and emergency care, hospital treatment and surgery, prescription drugs, and more. Riders for chiropractic care and alcohol and chemical dependency rehabilitation treatment are also available.. Member benefits, utilization management and authorization requirements, and customer service and claims processes are the same as for our HMO Colorado plans
Hospitals: The HMOSelect network includes the following facilities:
| Centura Health’s Denver metro facilities|
Avista Adventist Hospital
Littleton Adventist Hospital
Parker Adventist Hospital
Penrose Adventist Hospital
Porter Adventist Hospital
St. Anthony Central Hospital
St. Anthony North Hospital
| The Children’s Hospital|
| Craig Rehabilitation Hospital|
| Denver Health Medical Center|
| National Jewish Medical and Research Center|
| University of Colorado Hospital|
network includes more than 2,000 physicians. All providers with admitting privileges to one of the participating hospitals were invited to participate in the network. This doesn’t mean all providers who have admitting privileges to one of the participating hospitals have signed an HMOSelect
Amendment to their Provider Agreement. Please see our provider directory
for a listing of physicians participating in the HMOSelect
As with the rest of the HMOSelect
network, the ancillary provider network is limited. Please see our provider directory
for a listing of participating ancillary providers in the HMOSelect
| Members must select a PCP when enrolling.|
| Members have open access to physician specialists in the HMOSelect network without a referral from their PCP.|
| Member benefits, utilization management and authorization requirements, and customer service and claims processes are the same as for our HMO Colorado plans.|
Identifying HMOSelect Members
All member ID numbers will include the XFB or XFC alpha prefix.
Health Plan ID Cards
Please see the Membership Identification
section for a sample HMOSelect
health plan ID card