1

Provider Orientation

For providers seeing

Anthem Blue Cross and

Blue Shield Medicaid

members

22

Coverage area

The Kentucky Cabinet for Health and Family Services (CHFS) awarded

Anthem Blue Cross and Blue Shield Medicaid (Anthem) the bid to be

one of the contracted managed care organizations (MCOs) for the

Affordable Care Act (ACA) Medicaid expansion. As of July 1, 2015, this

includes all eight regions.

33

Agenda

• Who we are

• Medicaid membership

• Member eligibility

• Member benefits

• Value-added benefits

• Required Medicaid number

• Medicaid provider

website/registration

• Precertification guidelines

• Updating your information

• Claim submission

• Electronic payment services

• Grievances and appeals

• Key provider responsibilities

• Credentialing process

• Cultural Competency

• Translation services

• National vendors

• Laboratory services

• Pharmacy program

• Provider support

– Disease management

– Quality management

– Key contacts

44

Who we are

• As a leader in managed health care services for

the public sector,

Anthem helps low-income families, children,

pregnant women and people with disabilities get

the care they need.

• We help to coordinate physical and behavioral

health care, and we offer education, access to

care and disease management programs.

55

Medicaid membership

• As of January 1, 2014, enrolled membership is

comprised of those who were newly eligible

through ACA.

• As of July 1, 2014, Anthem is an option for other

populations including Temporary Assistance for

Needy Families (TANF) and Children’s Health

Insurance Plan (CHIP) in all regions except

Region 3.

• As of July 1, 2015, Anthem is an option for other

populations including TANF and CHIP in Region 3.

66

Member eligibility

• Medicaid eligibility is determined by the member’s Department for

Community Based Services (DCBS) in the county in which the

member resides.

• The Department for Medicaid Services (DMS) provides eligibility

information to Anthem on a daily basis.

• Eligibility begins on the first day of each calendar month when the

member joins.

• A member must select a PCP.

– A member’s PCP can be changed within 24 hours from the time

the change request has been made.

• Dual-eligible members, members presumptively eligible, disabled

children and foster care children are not required to have a PCP.

• A member can see a specialist without a referral.

77

Core member benefits

We offer the following no cost benefits and services:

• SafeLink mobile phone service with extra minutes and texts

• Hearing aid batteries

• Tornado preparedness kit

• Prenatal program consisting of resources and coaching

Care On Call (1-866-824-2544; Spanish 1-866-864-2545)

• Members can call our 24-hour Care on Call for health advice 7 days

a week, 365 days a year.

• When a member uses this service, a report is faxed to the member’s

PCP office within 24 hours of receipt of the call.

88

Value-added benefits

• No copays

• No cost sports physicals for members 6 to 18

• No cost Boys & Girls Club memberships for kids age 6 to 19, with

after-school care, at participating locations

• Prenatal rewards program:

– No cost portable crib or car seat for members who go to their PCP

or OB/GYN at least seven times while they are pregnant

– No cost reloadable gift cards

• $50 when kids get their checkups on time

• $50 for post-partum checkups

• $25 for 1st trimester visit

• No cost hearing aid batteries (sizes 10, 13, 312 or 675)

For more information on value-added benefits and sponsorship

opportunities, contact Rhonda Petr at rhonda.petr@anthem.com

or 1-502-619-6816.

99

Member ID card

1010

Required Medicaid ID number

• In order to be reimbursed for Medicaid services,

providers are required to have a Medicaid ID

number.

• If a potential provider does not have a Medicaid

number assigned, Anthem will work with the

provider and the state to complete the

necessary paperwork and assist the provider

with obtaining a Medicaid ID number.

• Forms are available on the DMS website

(http://chfs.ky.gov/dms/provEnr/Forms.htm).

1111

Provider website

https://mediproviders.anthem.com/ky

• The provider website is available to all providers regardless of

participation status.

• Registration is required to perform many key transactions.

– This is separate and distinct from existing MyAnthem

registration.

– An Anthem Medicaid ID is required for registration.

1212

Provider website (public information)

Registration and login not required for access.

Key tools include:

• Claims forms

• Precertification lookup tool

• Provider manual

• Clinical Practice Guidelines

• News and announcements

• Provider directory

• Fraud, waste and abuse

• Formulary

1313

Provider website (secure information)

Registration and login required for access.

Key tools include:

• Precertification submission

• Precertification status lookup

• Pharmacy precertification

• Primary care physician (PCP) panel listings

• Member eligibility

• Claim status

Note:

• An Anthem Medicaid ID is required for registration.

• Some functionality is accessed via the Availity Portal.

1414

Precertification lookup

• Submit precertification requests through our provider website, via

fax or by calling Provider Services.

• Check the status of your request on the website or by calling

Provider Services.

• Our Precertification Lookup Tool lets you search by market,

member’s product and Current Procedural Terminology (CPT).

1515

Precertification requirements

• Cardiac rehabilitation

• Chemotherapy

• Chiropractic services

• Diagnostic testing

• DME — all rentals (See provider

manual for purchase requirements.)

• Home health

• Hospital admission

• Physical, occupational and speech

therapy treatment

• Sleep studies

• Behavioral health

• Electroconvulsive therapy

• Inpatient psychiatric treatment

• Inpatient substance abuse

treatment for pregnant women

• Intensive outpatient treatment

• Psychiatric residential treatment

• Partial hospital treatment

• Psychological and

neuropsychological testing

• Certain Community Mental Health

Center services

Utilization Management

1-855-661-2028

Note: This list is not comprehensive. Refer to our provider

manual for an all-inclusive list.

1616

Provider Maintenance Form

Key changes can be requested directly on the provider website

(https://mediproviders.anthem.com/ky > Provider Forms > Provider

Maintenance Form):

• Change practice names

• Add or update sites, billing/remit addresses, email addresses and

phone/fax numbers

• Change Tax ID numbers (a new signed contract is required)

• Change provider names

• Add or term providers

• Add NPI and Medicare numbers

• Initiate the Council for Affordable Quality Healthcare (CAQH) numbers

for new providers

1717

Claims submission

There are several ways to submit claims:

• Availity (https://www.availity.com)

• Electronically

– Professional payer ID:00660

– Institutional payer ID:00160

• Paper submission:

Anthem Blue Cross and Blue Shield Medicaid

Attn: Claims

P.O. Box 61010

Virginia Beach, VA 23466-1010

Filing limit: 180 days from the date of service unless otherwise stated in

contract

1818

Rejected versus denied claims

• There are two types of notices you may get in response to your

claim submission — rejected or denied.

• You can find claims status information on the website or by calling

Provider Services.

• Should you need to appeal a claim decision, submit a copy of the

EOP, letter of explanation and supporting documentation.

Rejected

Does not enter the adjudication system due to missing or incorrect information

Denied

Goes through the adjudication process but is denied for payment

1919

Electronic payment services

If you sign up for electronic funds transfer (EFT) and Electronic

Remittance Advice (ERA), you can:

• Start receiving ERAs and import the information directly into your

patient management or patient accounting system.

• Route EFTs to the bank account of your choice.

• Create your own custom reports within your office.

• Access reports 24 hours a day, 7 days a week.

Where to enroll, update or change:

• EFT and ERA (both) or EFT only:

https://solutions.caqh.org/bpas/Default.aspx

• ERA only: https://www.anthem.com/edi/

Electronic Data Interchange (EDI) Hotline:

1-800-590-5745

2020

Grievances and appeals

• Separate and distinct appeal processes are in place for our

members and providers, depending on the services denied or

terminated.

• Please refer to the denial letter issued to determine the correct

appeals process.

• Appeals of medical necessity and administrative denials must be

filed within 30 calendar days of the postmark date of our denial

notification.

– Mail appeals to:

Anthem Blue Cross and Blue Shield

Central Appeals Processing

P.O. Box 61599

Virginia Beach, VA 23429

2121

Key provider responsibilities

• Provide preventive health screenings (for PCPs).

• Comply with ADA standards; do not discriminate against members

with mental, developmental and physical disabilities.

• Notify Anthem of changes including billing address, etc.

• Understand and educate members on advance directives.

• Comply with HIPAA requirements and records keeping standards.

• Recommend preventive care services to all members.

• Identify behavioral health needs.

• Document and bill accurately; if a provider suspects fraud, waste or

abuse, it must reported to Anthem.

• Comply with access standards including wheelchair accessibility.

• Provide appointment availability and after-hours access.

2222

Credentialing process

• Credentialing follows the existing Anthem

process in Kentucky.

• Some providers who were not previously

required to be credentialed may need to be

credentialed under the Medicaid program.

• Please notify us if you have any changes in

licensure, demographics or participation status.

• In order to participate in the Medicaid program,

providers must have a Kentucky Medicaid ID.

2323

Cultural Competency

• We expect our providers and their staff to gain and continually

increase in knowledge of and skill with, improved attitudes about

and sensitivities to diverse cultures.

• This results in effective care and services for all people by taking

into account each person’s values, reality conditions and linguistic

needs.

• Anthem will provide training to providers on matters related to

meeting the needs of economically disadvantaged and culturally

diverse individuals.

2424

Translation services

• Translation services are available

24 hours a day, 7 days a week in more than

170 languages.

• In-person translations – Case Management:

1-855-661-2027

• Telephonic translation – Provider Services:

1-855-661-2028

2525

National vendors

Dental: DentaQuest

• Phone: 1-800-508-6787

• Website: www.DentaQuest.com/Kentucky

Vision: eyeQuest

• Phone: 1-888-696-9551

• Website: www.eye-quest.com

• Email: providerservices@dentaquest.com

Pharmacy: IngenioRx

• Phone: 1-855-661-2028

2626

Laboratory services

• Notification or precertification is not required if lab

work is performed in a physician’s office or

participating hospital outpatient department (if

applicable) or by one of our preferred lab vendors.

• Testing sites must have CLIA certificate or a waiver.

2727

Pharmacy program

• The Preferred Drug List (PDL) and formulary are

available on our website.

• Prior authorization is required for:

– Non-formulary drug requests.

– Brand-name medications when generics are

available.

– High-cost injectable and specialty drugs.

– Any other drugs identified in the formulary as

needing prior authorization.

Note: This list is not all-inclusive and is subject to

change.

2828

Disease Management

• Asthma

• Bipolar disorder

• Congestive heart failure

• COPD

• Coronary artery disease

• Diabetes

• HIV/AIDS

• Hypertension

• Major depressive disorder

• Obesity

• Schizophrenia

• Substance abuse

• Transplants

We offer programs for members living with:

To refer members, call 1-855-661-2028.

2929

Quality Management

Our Quality Management team continually analyzes

provider performance and member outcomes for

improvement opportunities.

3030

Key contacts

• Provider Services: 1-855-661-2028

• Member Services: 1-855-690-7784

• Provider Relations: 1-855-661-2027

• Nurse Triage Line: 1-866-864-2544

• Precertification

– Phone: 1-855-661-2028

– Fax: 1-800-964-3627

• Pharmacy prior authorization

– Phone: 1-855-661-2028

– Fax: 1-844-879-2961

Website:

https://mediproviders.anthem.com/ky

Paper claims submission:

Anthem Blue Cross and Blue Shield Medicaid

Attn: Claims

P.O. Box 61010

Virginia Beach, VA 23466-1010

Electronic claims submission:

Professional payer ID: 00660

Institutional payer ID: 00160

3131

Thank you

https://mediproviders.anthem.com/ky Anthem Blue Cross and Blue Shield Medicaid is the trade name of Anthem Kentucky Managed Care Plan, Inc., independent

licensee of the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

IngenioRx, Inc. is an independent company providing pharmacy benefit management services on behalf of Anthem Blue Cross and

Blue Shield Medicaid.

AKYPEC-2127-19 July 2019