September 06, 2019
Area(s) of Interest: Payor Issues and Reimbursement Practice Management
Physicians are reminded that October 1, 2019, marks the effective date of several important Anthem Blue Cross policy changes.
Reduction in the timely filing requirement for Anthem commercial and Medicare Advantage claims to 90 days from the date of service begins October 1, 2019.
Under the new requirement, all claims submitted on or after October 1, 2019, will be subject to the new 90 day filing requirement. Currently, Anthem requires physicians to submit all professional claims for commercial and Medicare Advantage plans within 365 days of the date of service.
Pre-Payment Modifier Audit
Anthem will begin conducting pre-payment reviews for claims with certain modifiers for dates of service on or after October 1, 2019. According to the June 27, 2019, notice, the pre-payment modifier review will focus on claims billed with modifiers 25, 59, 57, LT/RT and other anatomical modifiers to determine whether it is appropriate for the modifier to bypass the edit.
According to the notice, registered nurses and coders will review claims that are pended to determine whether the utilization of the modifier is appropriate. Anthem has advised the California Medical Association (CMA) that the review may also include a review of past claims and provider specialty to make a determination on whether it believes use of the modifier was appropriate. Based on that review, the claim will either be paid or denied. There will be no request for medical records prior to a claim determination being made.
Physicians who wish to dispute a denial will need to submit a written appeal along with medical records through the Anthem Provider Dispute Resolution process.
Increased penalty for failure to obtain pre-certification
Anthem Blue Cross notified physicians in July that it will increase the reimbursement penalty for failing to comply with Anthem’s pre-certification requirements for commercial plan members. Effective for dates of service beginning October 1, 2019, Anthem will impose a 50% reduction in claim reimbursement for providers who fail to obtain pre-certification as required for certain inpatient or outpatient elective services. The 50% penalty will also apply in instances where a provider has failed to notify Anthem of an emergency admission within the required 48-hour timeframe. If the 48-hour period ends on a weekend or holiday, this period will be extended to the end of the next business day.
CMA remains very concerned with the adverse impacts of these new policies upon physicians. We have engaged with the American Medical Association and other state medical societies to escalate these issues so we can continue the dialogue with Anthem regarding our concerns.
Physicians with questions regarding these policy changes can contact Anthem Network Relations via email at CaContractSupport@anthem.com.