Anthem MSMA Anthem MSMA PresentationPresentation

April 2014April 2014

This presentation contains proprietary information of Anthem Blue Cross and Blue Shield. Any redistribution or other use is strictly prohibited.

ObjectivesObjectives• Anthem MO Provider NetworksAnthem MO Provider Networks• Anthem MO ProductsAnthem MO Products• Member ID CardsMember ID Cards• BlueCardBlueCard• New Exchange Levels/Products/CardsNew Exchange Levels/Products/Cards• Claims Filing GuidelinesClaims Filing Guidelines• AddressesAddresses• Claim Escalation Process/Network ManagementClaim Escalation Process/Network Management• Online Self Service ToolsOnline Self Service Tools• Question & Answer Question & Answer

Anthem Mo Provider Anthem Mo Provider NetworksNetworks

Anthem MO Provider Networks Anthem MO Provider Networks

• Blue Access Network• Blue Access Choice Network• Blue Preferred Network• Pathway/Pathway X• Medicare Advantage Network• Federal Programs• Traditional

Member ID CardsMember ID Cards

Member ID CardsMember ID Cards

Members Identification NumberMembers Identification Number-- Member identification Member identification numbers are found on the identification card under the numbers are found on the identification card under the member's name. The identification numbers contain member's name. The identification numbers contain three letter prefixes which are critical in the routing and three letter prefixes which are critical in the routing and processing of your claim. processing of your claim.

NetworkNetwork - Knowing the member’s network will assist you - Knowing the member’s network will assist you in identifying the applicable reimbursement schedule. in identifying the applicable reimbursement schedule. You need to have this information when registering You need to have this information when registering members in your office. members in your office.

Member ID CardsMember ID Cards Steps to determine reimbursement schedule:Steps to determine reimbursement schedule:

1.1. First look for Blue Access, Blue Access Choice, Blue Preferred or Pathway First look for Blue Access, Blue Access Choice, Blue Preferred or Pathway network on the members id card.network on the members id card.

2.2. If you do not locate Blue Access, Blue Access Choice, Blue Preferred or If you do not locate Blue Access, Blue Access Choice, Blue Preferred or Pathway network on the id card then look at the suitcase.Pathway network on the id card then look at the suitcase.

3.3. If the suitcase is empty or you do not locate a suitcase please contact the If the suitcase is empty or you do not locate a suitcase please contact the number on the back of the id card, as the member may not have out of number on the back of the id card, as the member may not have out of network benefits. network benefits.

• Please remember:Please remember: The suitcase identifies members with benefits when they The suitcase identifies members with benefits when they travel. If a member receives services outside of Anthem’s service area, that travel. If a member receives services outside of Anthem’s service area, that member would need to access a provider in that Blue plan’s network to member would need to access a provider in that Blue plan’s network to receive in-network benefit levels. receive in-network benefit levels.

• (Example)(Example)-An Anthem member travels to Kansas and needs to see a Kansas -An Anthem member travels to Kansas and needs to see a Kansas provider. If the suitcase had a PPO then the patient would need to seek out a provider. If the suitcase had a PPO then the patient would need to seek out a PPO provider in the Kansas plan to receive their maximum benefit. PPO provider in the Kansas plan to receive their maximum benefit.

Member ID CardsMember ID Cards

BlueCardBlueCard

Blue CardBlue Card

• The Blue Cross and Blue Shield Association (BCBSA) is a The Blue Cross and Blue Shield Association (BCBSA) is a national federation of 39 independent, community-based and national federation of 39 independent, community-based and locally operated Blue Cross and Blue Shield companies. locally operated Blue Cross and Blue Shield companies.

• BlueCard® launched in 1994. This program enables member who BlueCard® launched in 1994. This program enables member who are traveling or living in another Plan's service area to receive the are traveling or living in another Plan's service area to receive the same healthcare service benefits of their home Plan.same healthcare service benefits of their home Plan.

What is BlueCard?What is BlueCard?

•The BlueCard® Program links health The BlueCard® Program links health care providers and the independent care providers and the independent Blue Cross and Blue Shield Plans Blue Cross and Blue Shield Plans across the country and around the across the country and around the world through a single electronic world through a single electronic network for claims processing network for claims processing reimbursement. reimbursement.

•Your local Blue Plan is your single Your local Blue Plan is your single point of contact for claimspoint of contact for claims

1. Member ofanother Blue Planreceives servicesfrom you, theprovider

2. Providersubmits claim tothe local BluePlan

3. Local Blue Planrecognizes BlueCardmember and transmitsstandard claim format tothe the member’s BluePlan

4. Member’s BluePlan adjudicatesclaim according tomember's benefitplan

5. Member’s Blue Planissues an EOB to themember

6. Member’s BluePlan transmits claimpayment dispositionto your local BluePlan

7. Your localBlue Plan paysyou, the provider

How Blue Card Works

Examine Insurance ID CardExamine Insurance ID CardLogosLogos

BlueCross BlueShieldof Anywhere

An Independent licensee of theBlue Cross and Blue Shield Association

DOE, JOHN

Identification No. XYZ123456789

BS Plan Code 621 BC Plan Code 121Group No. 123456

Sect. 0000

BlueCard: BlueCard: Verifying Eligibility and BenefitsVerifying Eligibility and Benefits

• Ask members for their current member Ask members for their current member ID cardID card

• Check eligibility and benefits through Check eligibility and benefits through Availity or by calling BlueCardAvaility or by calling BlueCard Eligibility Eligibility line 1.800.676.BLUE (2583)line 1.800.676.BLUE (2583)

• Verify the member’s cost sharing amount Verify the member’s cost sharing amount (copay) before processing payment(copay) before processing payment

Submitting BlueCardSubmitting BlueCard®® Claims Claims (cont’d)(cont’d)

BlueCard ExclusionsBlueCard Exclusions FEPFEP Medicare RiskMedicare Risk Stand-alone dental and prescription drugsStand-alone dental and prescription drugs Vision and hearingVision and hearing

Anthem Missouri ExchangesAnthem Missouri Exchanges

New Provider NetworkNew Provider NetworkProvider Network For Individual Business ON Provider Network For Individual Business ON

Exchange: Pathway XExchange: Pathway X

Provider Network For Individual Business OFF Provider Network For Individual Business OFF Exchange: Pathway Exchange: Pathway

Same providers for both Individual business ON Same providers for both Individual business ON and OFF Exchangeand OFF Exchange

A Focused Network of professional and facility A Focused Network of professional and facility providersproviders

1717

Missouri Metal Level Plans On and Off Exchange

ON EXCHANGEON EXCHANGE OFF EXCHANGEOFF EXCHANGE

Small Group - On-ExchangeNetwork Name – Blue Preferred

Product Type

Prefix

Anthem Bronze Direct Access PPO JWU

Anthem Silver Direct Access PPO JWU

Anthem Gold Direct Access PPO JWU

Small Group – Off-Exchange Network Name – Blue Access, Blue Access Choice, or Blue Preferred

Product Type

Prefix

Anthem Core Direct Access PPO YCB, YCA, YCC, YCD, YCE

Anthem Essential Direct Access PPO YCB, YCA, YCC, YCD, YCE

Anthem Preferred Direct Access PPO YCB, YCA, YCC, YCD, YCE

Anthem Small Group Products - MO

Individual - On-ExchangeNetwork Name - Pathway X

Product Type

Prefix

Anthem Bronze Direct Access PPO JWZ, YCH

Anthem Silver Direct Access PPO JWZ, YCH

Anthem Gold Direct Access PPO JWZ, YCH

Individual – Off-ExchangeNetwork Name - Pathway

Product Type

Prefix

Anthem Core Direct Access PPO JWY

Anthem Essential Direct Access PPO JWY

Anthem Preferred Direct Access PPO JWY

Anthem Individual ProductsMissouri

2121

What Does the ID Card Look Like?

Missouri Medical Off Exchange - Individual

2222

What Does the ID Card Look Like?

Missouri Medical On Exchange - Individual

What is the 90-Day Grace Period?

• Individual members who purchase their health plan on the marketplace are eligible for a premium subsidy from the government. The ACA mandates a three month grace period for delinquent premium payments.

• It applies after the individual has paid at least one month of premium within the benefit year.

How will the 90-Day Grace Period be implemented?

• Anthem will process claims for services received during the first month

• Providers notified of grace period on remittance for services rendered during second and third month.

• During the second and third months, if payment is not received, the health plan will be terminated, claims for services received during the second and third month will be denied.

• Payment made for dates of service within the first month will not be retracted

• Impacted claims will be automatically adjusted once a member pays their premium, or is terminated (after the end of the grace period).

 

Anthem Claims FilingAnthem Claims FilingGuidelinesGuidelines

Claims Filing GuidelinesClaims Filing Guidelines

• File claims within 180 day from the date the File claims within 180 day from the date the services were rendered or date of other carriers services were rendered or date of other carriers EOB. EOB. ***Unless your contracts specifies something else.******Unless your contracts specifies something else.***

• Use appropriate claim processing forms and Use appropriate claim processing forms and CMS billing codesCMS billing codes

• Claims form must have all fields completed.Claims form must have all fields completed.• File claims electronicallyFile claims electronically• File claims to your local BluePlan File claims to your local BluePlan

AddressesAddresses

Addresses Addresses

Address UseAddress Use AddressAddress

Claims Claims Anthem Blue Cross and Blue Shield Anthem Blue Cross and Blue Shield

P.O. Box 105187P.O. Box 105187

Atlanta, GA 30348 Atlanta, GA 30348

CorrespondenceCorrespondence Anthem Blue Cross and Blue Shield Anthem Blue Cross and Blue Shield

P.O. Box 105557P.O. Box 105557

Atlanta, GA 30348 Atlanta, GA 30348

FEP Claims/CorrespondenceFEP Claims/Correspondence Anthem Blue Cross and Blue Shield Anthem Blue Cross and Blue Shield

P.O. Box 105557P.O. Box 105557

Atlanta, GA 30348 Atlanta, GA 30348

Grievance and Appeals Grievance and Appeals Anthem Blue Cross and Blue Shield Anthem Blue Cross and Blue Shield

P.O. Box 105568P.O. Box 105568

Atlanta, GA 30348 Atlanta, GA 30348

UM AppealsUM Appeals Anthem Blue Cross and Blue Shield Anthem Blue Cross and Blue Shield

P.O. Box 105662P.O. Box 105662

Atlanta, GA 30348 Atlanta, GA 30348

Provider Claims Escalation Provider Claims Escalation Process/Network Process/Network

Management Management

Escalation ProcessEscalation ProcessIn an effort to better serve Providers, we have initiated an escalation process In an effort to better serve Providers, we have initiated an escalation process

to assist with claim/issue resolution more quickly and efficiently. It is to assist with claim/issue resolution more quickly and efficiently. It is critical to document the reference numbers given on both telephone critical to document the reference numbers given on both telephone

contacts and secured messagingcontacts and secured messaging..

Provider Service – Telephone Inquiries Provider Service – Telephone Inquiries We ask that you contact Provider Service initially. In the event that your We ask that you contact Provider Service initially. In the event that your

claim/issue is not handled to your satisfaction, we ask that you ask for a claim/issue is not handled to your satisfaction, we ask that you ask for a supervisor. If the rep is sending your claim for adjustment or additional supervisor. If the rep is sending your claim for adjustment or additional research, we ask that you allow 30 days for resolution. If after the 30 day research, we ask that you allow 30 days for resolution. If after the 30 day period, your claim/issue is still unresolved, we ask that you call and period, your claim/issue is still unresolved, we ask that you call and request to speak to a supervisor.request to speak to a supervisor.

Escalation Process (cont.)Escalation Process (cont.)Secured Messaging (Currently in review)Secured Messaging (Currently in review) If you send a secured message and do not receive If you send a secured message and do not receive

satisfactory response, please reply to the original secured satisfactory response, please reply to the original secured message and request that the inquiry be escalated to a message and request that the inquiry be escalated to a supervisor. Please include your name and a number where supervisor. Please include your name and a number where you can be reached.you can be reached.

In both scenarios, once you have escalated your claim/issue please In both scenarios, once you have escalated your claim/issue please allow 30 days for research/adjustment. allow 30 days for research/adjustment.

If you still require additional assistance after exhausting these If you still require additional assistance after exhausting these avenues, please contact your Network Consultant and provide avenues, please contact your Network Consultant and provide both reference numbers or secured message transaction both reference numbers or secured message transaction number.number.

In order for this procedure to work, please always allow the In order for this procedure to work, please always allow the front end reps the opportunity to resolve your issue firstfront end reps the opportunity to resolve your issue first. .

Improving the Provider Experience:Improving the Provider Experience:Provider Escalation process (continued)Provider Escalation process (continued)

Network Management Network Management continues to support questions related to:continues to support questions related to:

Online Self Service Online Self Service ToolsTools

Online Tools Online Tools

Sites to use for Anthem business:Sites to use for Anthem business:

www.Anthem.com---unsecure web portal web portal

MyAnthem----secured web portalMyAnthem----secured web portal

wwwwww.availity.com---multi-payor portal portal

Self-Service ToolsSelf-Service ToolsElectronic Data Interchange (EDI) Electronic Data Interchange (EDI) • With EDI you can submit and receive transactions from your With EDI you can submit and receive transactions from your

computer system. computer system. • Connect directly to Anthem using vendor software or through an Connect directly to Anthem using vendor software or through an

approved clearing house.approved clearing house.

Transactions Available through EDI:Transactions Available through EDI: Claims submissionClaims submission Electronic Remittance AdviceElectronic Remittance Advice Electronic Funds TransferElectronic Funds Transfer EligibilityEligibility BenefitsBenefits Claims StatusClaims Status

Self Service ToolsSelf Service Tools

Interactive Voice Reponses (IVR)Interactive Voice Reponses (IVR)

Phone access to real-time:Phone access to real-time: EligibilityEligibility BenefitsBenefits Claims statusClaims status

• Use for one or multiple membersUse for one or multiple members• Listen to the information or have it sent via faxListen to the information or have it sent via fax• FEP claims detailFEP claims detail

Self Service Tools – ICRSelf Service Tools – ICR(Interactive Care Reviewer)(Interactive Care Reviewer)

Our new online tool offers a streamlined precertification Our new online tool offers a streamlined precertification process using cutting-edge IBM Watson technology and process using cutting-edge IBM Watson technology and can be accessed via Availity to request inpatient and can be accessed via Availity to request inpatient and outpatient procedures for many members covered by outpatient procedures for many members covered by Anthem and BlueCard plans. Some benefits are:Anthem and BlueCard plans. Some benefits are:

Reduces the need to faxReduces the need to fax No additional costNo additional cost Access almost anywhereAccess almost anywhere Comprehensive view of UM requestsComprehensive view of UM requests Easy access via Availity (Your PAA can grant you access to Easy access via Availity (Your PAA can grant you access to

Authorizations and you can start right away)Authorizations and you can start right away)

Interactive Care Reviewer (cont.)Interactive Care Reviewer (cont.)

Additional webinar training is available to learn more Additional webinar training is available to learn more about the features and benefits. Go to: about the features and benefits. Go to:

https://www144.livemeeting.com/lrs/1100001891/ Registration.aspx?pageName=83vbvn5cvr00ngx4Registration.aspx?pageName=83vbvn5cvr00ngx4

Future planned enhancements include:Future planned enhancements include: Expand the use to incorporate behavioral health Expand the use to incorporate behavioral health

and additional procedures.and additional procedures.

Self Service ToolsSelf Service ToolsE-ReviewE-Review• Secured email tool that can be used for Inpatient, Outpatient Secured email tool that can be used for Inpatient, Outpatient

precertification and predetermination for local Anthem members.precertification and predetermination for local Anthem members.

Imaging and Specialty Rx-Web ToolsImaging and Specialty Rx-Web Tools• Real time preauthorization's for Radiology, Echocardiography, Real time preauthorization's for Radiology, Echocardiography,

Radiation Oncology, Specialty Pharmacy, Sleep Study.Radiation Oncology, Specialty Pharmacy, Sleep Study.

Medical Policy and Preauthorization Routing ToolMedical Policy and Preauthorization Routing Tool• This tool will allow providers to access the medical policies and This tool will allow providers to access the medical policies and

preauthorization information for other blue plans.preauthorization information for other blue plans. BlueCard members –out-of-area membersBlueCard members –out-of-area members

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Steps to access the routing toolSteps to access the routing tool..Step 1: Locate the blue Medical Policy, Clinical UM Guidelines and Pre-Cert Requirements box on the left side of the page and click “Enter”.

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Steps to access the routing toolSteps to access the routing tool..

•Step 2: Click on the appropriate link to access the information that is needed.

•The first two links are for local Anthem members. The bottom two links are for BlueCard out-of area members.

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How to use the tool.How to use the tool.Step 3: Select the type of information requested, enter the first three letters of member’s identification number located on the ID card in the alpha prefix box and click “GO”.

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How to use the tool.How to use the tool.Step 4: Review the disclaimer stating that the user will be leaving Anthem’s site and being directed to an external site not affiliated with Anthem and click “Continue”. This disclaimer will only appear for BlueCard inquiries.

4444

It Worked!It Worked!1. It worked! The user has been routed to Blue Cross Blue Shield of Illinois’s Medical Policy web page

2. Here the user can view all medical policies for BCBSIL.

3. Please note that most Blue plans have search function capability that will allow the user to search for a specific procedure by name or code.

Self Service ToolsSelf Service ToolsSSecure Messagingecure Messaging

•Online secure messaging tool used to contact the PSU regarding Online secure messaging tool used to contact the PSU regarding a claima claimLocal claim, BlueCard, FEP Local claim, BlueCard, FEP

CommunicationsCommunications•E-UpdatesE-Updates•Network NewsNetwork News

Provider Maintenance Form Provider Maintenance Form (Under the Answers@Anthem Tab)(Under the Answers@Anthem Tab)•Electronic Form Required to Begin the Credentialing ProcessElectronic Form Required to Begin the Credentialing Process•Add/Delete Providers or ProductsAdd/Delete Providers or Products•Make Any Demographic Changes (Address, Phone, Email, Fax)Make Any Demographic Changes (Address, Phone, Email, Fax)

Self Service ToolsSelf Service ToolsAdditional Tools:Additional Tools:• Quick Contact SheetQuick Contact Sheet• Network Relations Consultant Territory ListingNetwork Relations Consultant Territory Listing• Clinical Data Submission ToolsClinical Data Submission Tools• Provider Adjustment FormProvider Adjustment Form• Medical Policy/Clinical UM GuidelinesMedical Policy/Clinical UM Guidelines• Clinical EditsClinical Edits• Product and Benefit informationProduct and Benefit information• Appeals ProcessAppeals Process• Provider ManualProvider Manual

Self Service ToolsSelf Service Tools

AvailityAvaility

Secure web portal that offers one easy place to Secure web portal that offers one easy place to take care of administrative, clinical and take care of administrative, clinical and financial health plan tasks-one site for your financial health plan tasks-one site for your transactions with multiple health plan.transactions with multiple health plan.

•Eligibility•Benefits•Claims•Patient Care Summary•Care Reminders•Interactive Care Reviewer

•Imaging and Specialty RX•Secure Messaging •Member Certificates•Payer Resources Tab •Click Wrap Registration

Question and AnswerQuestion and Answer

In most of Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name for RightCHOICE® Managed Care, Inc. (RIT), In most of Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name for RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark. The Blue Cross and Blue Shield names and symbols are Independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. registered marks of the Blue Cross and Blue Shield Association.