Category: Medicaid


The new Provider Manual is now live on our provider website, This recently updated manual contains everything you need to know about our programs and how we work with you to provide quality care to our members. You can access the provider manual by visiting > Manuals, Directories, Training & More > Provider Manuals & Directories. The information below explains how Anthem Blue Cross and Blue Shield Medicaid (Anthem) conducts prepayment review and appears in section 11.8.1 of the Provider Manual.


Anthem routinely conducts reviews of members' medical records to ensure accuracy of provider payments. Compliance with requests to submit medical records is a standard component of our provider contracts. Anthem’s prepayment review program evaluates medical records and validates services are billed appropriately. This process does not impact timely adjudication of claims submitted with supporting medical records. Under the prepayment review program, Anthem will review all claims billed under identified codes prior to processing the claim to determine the appropriateness of the claim. Prepayment review includes any and all existing and future NPIs and TINs associated with the practice.  If a provider is placed under pre-payment review, a letter will be issued prior to the effective date outlining the specifics of the review.  The following guidelines apply to the program:

  1. Provider will be given 45 calendar days to submit documents in support of claims under prepay review. Claims will be denied if the requested documentation is not received by day 46.
  2. Anthem will deny a claim if the submitted documentation lacks evidence to support the billed service or code.
  3. Provider may appeal a denied claim within the proper timely filing guidelines as outlined in Sections 10.4 and 10.5 of this provider manual. 
  4. If the provider has sustained a 90 percent error-free claims submission rate to Anthem for 45 calendar days, the provider may be removed from the prepayment review process or Anthem will request permission from the Department for Medicaid Services to continue the prepayment review when it is determined necessary to prevent improper payments.” 


While we strive to keep our provider manual current, please be sure to check > Manuals, Directories, Training & More > Provider Manuals & Directories for the most up-to-date plan policy information.


If you have questions, contact your Provider Relations representative or call Provider Services at 1-855-661-2028.


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February 2020 Anthem Provider News - Kentucky