Anthem Blue Cross and Blue Shield (Anthem) in Connecticut, like many other employers during the pandemic including hospitals and care providers across the country, experienced staffing impacts. This compounded some workflow challenges Anthem was experiencing. It’s important to note that throughout this period we continued to process the vast majority of claims in a timely manner. That is not to say we didn’t incur various workflow and systems challenges in the wake of the pandemic. However, our work over the last several months has drastically reduced the number of claims payable. That work will continue.

 

Moving forward, we are holding ourselves to a higher standard for speed and accuracy in paying claims. Along with other enhancements, we expect this will create an improved overall care provider experience that will lead the industry.

What are we doing to elevate our performance? Why did this happen?

 

System modernization

 

In July 2021, Anthem in Connecticut upgraded to a new provider data management system – SPS. The system requires the provider to submit the claim with the correct Type 2 National Provider Identifier (NPI) information, which brings us in line with the industry standard. This investment in advanced technology is intended to significantly improve provider data accuracy and transparency, enhancing the overall provider experience.

 

Claims may have been rejected if the submitted information is not consistent with the correct Type 2 NPI or does not match the information in our provider management database. We continue to work toward reprocessing claims that were rejected for these reasons. We also are working to ensure we have the correct information to prevent claims rejection, which includes making outreach to providers whose claims are not processing properly. For more information, please refer to this communication we distributed in June 2021.

 

Protecting affordability

 

To mitigate inappropriate billing by some providers, Anthem and its vendors implemented a program focused on outlier providers. Most providers code and bill properly and are not impacted by this program. The program identifies billing patterns that fall outside expected parameters. This type of program is common across the industry and effective at monitoring inappropriate billing practices.

 

While we recognize its effectiveness, specialized care for behavioral health does not align with this program and applicable codes for behavioral health are excluded.

 

What can you do?

 

There are some steps providers can take to ensure their claims are processed as quickly as possible:

 

• Submit claims/attachments/records electronically through the Availity portal and ensure all necessary identifying data is included when submitting claims and/or required records.
  
  
• For large files (larger than 100MB) not initially accepted by the Availity portal please send information in increments, ensuring necessary identifying information (claim number, member ID, date of service, provider tax ID) is included on each submission.
  Note: If we cannot match your documentation to the appropriate claim, processing will be delayed.
  
  
• Double check to make sure you are using the correct National Provider Identifier (NPI) number.
  • Providers should include their group information, including billing NPI, in Box 33 of the submission form. Failure to do so means the claim will be rejected.
  • Box 32 is required to have service location. For more information, please refer to this communication we provided in October 2021.
    
    
• If you must submit required attachments by mail or by fax, we need proper identifying information to link them to the appropriate claim. Make sure to use the appropriate cover sheet with the proper identifying information – including claim number, member ID, date of service, provider tax ID.
  Note: Submissions via digital channels do not require this extra step.
  
  
• You can also find more information at anthem.com/provider.

 

Where can you go for help?

 

If you need assistance:

 

• Live Chat: Availity Chat with Payer is available during normal business hours, Monday through Friday, 9 a.m. to 5 p.m. ET. Get answers to your questions about eligibility, benefits, authorizations, claims status and more. Go to Availity portal and select Anthem from the payer spaces drop-down. Then select Chat with Payer and complete the pre-chat form to start your chat.

 

• By Phone: Connecticut providers can contact Anthem Provider Services for assistance during regular business hours, Monday through Friday, 8:30 a.m. to 5 p.m. ET by calling: 1-800 676 2583.

 

• Additional Assistance: If you are unable to resolve your concern using live chat or by phone, participating healthcare professionals ONLY can contact the Provider Experience team via email. You must include the reference number provided to you during your live chat or phone call in your submission.

 

If you wish to dispute a claim decision, you can begin the dispute process using Availity. We are unable to address disputes that have not been appropriately entered into this process.

 

Anthem values its relationships with care providers and considers you essential partners in fulfilling our mission to improve lives and communities. Together, we will continue our work to bring innovation and technology to the industry in order to simplify healthcare, create a better experience for consumers and control rapidly rising costs.

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