Reimbursement Guidelines and Policies

Please review the following reimbursement requirements that outline how Anthem will reimburse providers and facilities for certain services. This information can be found in the Connecticut Provider Manual which will be published July 1, 2020. Additional Professional and Facility Reimbursement Policies are published on anthem.com under Reimbursement Policies; please be sure to reference both sources for reimbursement-related information. Anthem reserves the right to review and revise reimbursement policies and requirements when necessary.

 

Blood, Blood Products, Processing, Storage and Administration

Blood and blood products such as platelets or plasma are reimbursable. Blood product processing fees (typing, serology and cross matching and blood storage) are also reimbursable. However, transportation charges are included in the reimbursement for the product itself and are not separately reimbursable. Blood and blood product administration services are reimbursable only on an outpatient basis when billed hourly, or as a flat rate with total eligible charges capped at the approved average semi-private room and board rate less discount, as submitted to Anthem. Blood and blood product administration services are not reimbursable on inpatient claims. 

 

Coding Requirements

Providers and facilities will submit claims in a format consistent with industry standards and acceptable to Anthem.

 

Courtesy Room

Facility shall not bill Anthem, Plan, and/or members for any charges related to use of a courtesy room in the provision of health services to a member. "Courtesy Room" means an area in the facility where a professional provider is permitted by facility to provide health services to members, which could otherwise be provided in an office setting.

 

Daily Supply or One Time Charge Fees/Items

Supply fees billed daily or one time, which are unidentified and unsupported by medical records or documentation are not reimbursable. Examples of daily supplies include those commonly used services and supplies provided in relatively equal quantities to all patients in similar circumstances. It also includes those inexpensive supplies and medications for which it is uneconomical to account separately.

 

Eligibility and Payment

A verification of eligibility is not a guarantee of payment.

 

Emergency Room Supply and Services Charges

The Emergency Room level reimbursement includes all monitoring, equipment, supply, time and staff charges. Reimbursement for the use of the Emergency Room includes the use of the room and personnel employed for the examination and treatment of patients. This reimbursement does not typically include the cost of physician services.

 

General Industry Standard Language

Per Anthem policy and the Agreement, provider and facility will follow industry standards related to billing. Examples of general industry standards include, but are not limited to, HCPCS, ICD10/CM, health service codes (also known as Revenue Codes) per the UB-04 Claim billing manual or subsequent forms CPT codes.

 

Instrument Trays

Charges for instrument trays for any procedure are included in the cost of the procedure and are not separately reimbursable. See Operating Room Time and Procedure Charges for additional information.

 

Lab Charges

Venipuncture, specimen collection, draw fees, phlebotomy, heel stick, processing fees, handling fees, blood storage and processing, blood administration. These charges are inclusive of the procedure/lab test performed and not separately reimbursable. 

 

Other Agreements

If facility currently maintains a separate Agreement(s) with Anthem solely for the provision and payment of home health care services, skilled nursing facility services, ambulatory surgical facility services, or other agreements that Anthem designates (hereinafter collectively "Other Agreement(s)"), said Other Agreement(s) will remain in effect and control the provision and payment of covered services rendered there under.

 

Personal Care Items

Personal care items used for patient convenience are not reimbursable. Examples include but are not limited to: breast pumps, deodorant, dry bath, dry shampoo, lotion, non-medical personnel, mouthwash, powder, soap, telephone calls, television, tissues, toothbrush and toothpaste. Items used for the patient which are needed as a direct result of a procedure or test are considered part of the room and board or procedure charges and are not separately reimbursable or billable to the patient. Examples include but are not limited to: bedpans, chux, hot water bottles, icepacks, pillows, sitz baths, and urinals.

 

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