Ensuring accurate and timely claims processing: essential tips for gatekeeper plans

Most of the Individual ACA plans from Anthem are gatekeeper plans. Gatekeeper plans (Pathway Guided Access, Pathway PCP Copay Choice, and Blue Value Individual Network HMO) require the involvement of a PCP to provide primary care and submit referrals for most specialists. Following these tips will help to ensure smooth coordination of care and reduce the risk of claim denials.

Tip #1: Validate your PCP/Specialty Indicator

All gatekeeper plan members have an assigned PCP which is listed at the top of their ID card (see sample below). Members who enroll in these plans for the first time on-exchange are assigned a PCP; assignment methodology is based on demographic data provided by the provider as well as historical claims data. Members can change their PCP any time through the Sydney App or by contacting Member Services.

To ensure appropriate member assignment and claims processing, providers must clearly indicate if they are practicing as a PCP or specialist. To qualify as a PCP and have members assigned, a provider needs to meet all of the following requirements:

1. They must specialize in family practice, pediatrics, internal medicine, or general practice.
2. The provider needs to ensure their credentialing application is through Availity Essentials if they are a PCP/specialist.
3. When completing the provider roster in Availity Essentials, the provider must indicate if they are practicing as a PCP or specialist. The PCP/Specialty Indicator is an important field that tells Anthem you wish to have members assigned, will provide members with primary care services, and submit referrals for members to see most specialists.
4. The provider is accepting new patients.

Physicians with primary care specialties who do not provide primary services (such as hospitalists and emergency doctors) should set their PCP/Specialty Indicator to Specialty to avoid being assigned members.

For more information about validating and updating demographic data, review CAA: Providers required to verify their online provider directory information ‑ Provider News.

Sample ID card:

Tip #2: Include supervising physician on midlevel claims

For successful claim processing, providers need to review and adhere to the contractual requirements for claim submission. In most cases, when submitting a claim for a midlevel provider such as a nurse practitioner or physician assistant, you should include the supervising physician on the claim.

Tip #3: Verify referral prior to providing specialist services

Referrals are required for members to see most specialists.

Referrals sent through Availity Essentials are good for 365 days, unless the provider’s office specifically lists a selected number of visits. Specialists should verify referral status prior to seeing the member for their scheduled appointment. If the specialist’s office cannot verify the referral through https://Availity.com, the specialist should inform the member prior to the services being rendered or claims will deny for no referral and become provider liability.

The specialist’s office may contact the PCP for a copy of the referral or direct the member to contact the PCP to have the referral notification updated.

The following specialists do not require referrals:

• Dermatologists
• OBGYNs
• Mental health and substance use providers
• Chiropractors
• Optometrists
• Ophthalmologists
• Oral Surgeons

When submitting specialist claims, include the referring doctor on the claim. The referring doctor should not be blank or the same as the rendering doctor.

Implementing these best practices will help care providers comply with gatekeeper plan requirements and significantly reduce the risk of claim denials, ensuring a smoother service experience for both care providers and members.