New strategic provider system coming in August 2023

Anthem will replace our legacy internal provider data management system for Anthem contracted providers in August 2023. Enhancing the overall provider experience, this investment in advanced technology will significantly improve care provider partners’ data accuracy and transparency. New system features strengthen Anthem’s ability to match submitted claims for more accurate pricing and processing.

Critical billing requirements
As part of this system upgrade, Anthem is enforcing the CMS billing guidelines that hold providers accountable for billing claims data correctly. (See CMS Regulations and Guidance.)

Beginning in early 2024, claims submitted with missing or incorrect billing national provider identifier (NPI) will be rejected and mailed back. Submitting claims with complete and correct data is critical to ensure Anthem can process your claims efficiently and accurately. All data fields on claims are used with building your claim records.

You should bill according to standard billing guidelines. As we approach the implementation date for our strategic provider system, we encourage you to review your billing practices carefully to ensure proper tax identification number (TIN), billing national provider identifier (NPI), and rendering provider information (if applicable) are submitted in the appropriate fields. As a reminder, if claims are submitted incorrectly, they will be rejected and mailed back for correction.

Electronic claims filing reminders
If you are filing professional claims electronically (supported by electronic data interchange EDI), below are tips for a successful claim submission:

• Billing provider— Loop (section) 2010:
  • When the billing provider is an organization healthcare provider, the organization’s NPI number is reported in field NM109.
  • The TIN of the billing provider must be reported in the REF segment of this loop.
  • The billing provider may be an individual only when the healthcare provider performing the services is an independent, unincorporated entity.
  • The billing provider address must hold a physical address and should not contain any of the following: Post Office Box, P.O. Box, PO Box, Lock Box, or Lock Bin.
• Rendering provider— Loop 2310:
  • This loop or section of the EDI file is required when the rendering provider’s NPI is different from that carried in Loop ID-2010AA-billing provider. If not required by the EDI implementation guide, do not send.
  • The rendering provider is the person or company who rendered the care.

Mail claims filing reminders
If you are filing a professional claim via mail:

• Facility information:
  • Include the address of the servicing facility — the address where services were rendered — in Box 32.
  • Include the servicing facility’s NPI — service location NPI — in Box 32a.
• Billing provider:
  • The billing provider’s complete name, address, and phone number must be in Box 33.
  • NPI must be reported in Box 33a (group’s organization or individual provider is an independent, unincorporated entity).
  • The TIN of the billing provider must be reported in Box 25.
• Rendering provider:
  • For claims that require a rendering provider, report the rendering provider NPI in Box 24J.

If using a clearinghouse, we suggest that you contact the clearinghouse to ensure proper claims filing and to alert the vendor of Anthem’s upcoming system change. Regular check-ins with your clearinghouse are key to identifying claim issues early.

Critical data requirements
Ensure that all your contracted providers are submitted to Anthem and on file prior to rendering services. This will alleviate any delay in claim processing and ensure the directory reflects correctly. It is a contractual requirement to submit physicians joining your group in a timely manner, prior to the physician rendering care to members.

Going forward
Watch for upcoming editions of Provider News, as we will continue to share information about our progress transitioning to the strategic provider system. We’ll keep you informed in advance of any impacts to our care provider partners.

For more information:

• Colorado – https://www.anthem.com/provider/policies

CMS Regulations and Guidance- https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c26pdf.pdf

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