August 05, 2019
Area(s) of Interest: Commercial Payors Practice Management
Anthem Blue Cross has notified physicians that it is amending sections of its Prudent Buyer Plan Participating Physician Agreement, significantly reducing the timely filing requirement for commercial and Medicare Advantage claims to 90 days from the date of service.
Currently, Anthem requires physicians to submit all professional claims for commercial and Medicare Advantage plans within 365 days of the date of service. Under the new requirement, all claims submitted on or after October 1, 2019, will be subject to the new 90 day filing requirement. However, as an example, the notice indicates that the change will impact claims with July dates of service if not submitted within 90 days.
While the change in Anthem’s claim submission timeframe meets the minimum timeframe allowed by law for contracting physicians, the California Medical Association (CMA) has received several calls from physicians concerned that the June 21 letter of the material contract change was not sufficient advance notice, given the policy change impacts claims with July dates of service.
As a result of CMA sponsored unfair payment practices law and the resulting regulations, plans are required to provide a minimum of 45 days prior written notice before instituting any changes or amendments about claim submission requirements.
CMA raised this concern with Anthem, but the payor believes it provided sufficient advance notice. CMA is assessing the issue to determine potential next steps.
Remember, even if a physician fails to submit a claim on time, California law provides a “good cause” exception that requires payors to accept and adjudicate a claim if the physician demonstrates, upon appeal, “good cause” for the delay.
Anthem has clarified that the change does not affect non-contracting physicians. As a reminder, California law states plans must allow a minimum of 180 days from the date of service for receipt of a claim for non-contracted providers.
Physicians with questions are encouraged to contact Anthem Network Relations at CaContractSupport@anthem.com.
For a summary of California's unfair payment practices law, see "Know Your Rights: Identify and Report Unfair Payment Practices" More information on timeframes for claim submission can be found in “Know Your Rights: Timely Filing Limitations” or in CMA health law library document #7511, “Payment Denials by Managed Care Plans and IPAs.” available free to members on CMA’s Reimbursement Assistance page.