Update to provider/facility UM reimbursement penalties and corresponding update to Provider/Facility Manual

Effective for dates of service beginning October 1, 2019, and after, we will increase the reimbursement penalty for failure to comply with our Utilization Management Program’s pre-certification requirements for services rendered to commercial plan members. Late pre-certifications, and late notices in the case of emergency admissions, are currently subject to a penalty and will be subject to the increase in the penalty.  Failure to comply with Anthem’s pre-certification requirements will result in reimbursement penalties of 50% to the provider and facility (for services managed by Anthem) or a 100% penalty/claim denial to the provider and facility (for high-cost radiology, sleep therapy and cardiology cases managed by AIM).

 

As a reminder, we require pre-certification prior to certain elective services in both the inpatient and outpatient settings. For an emergency admission, pre-certification is not required; however, you must notify us of the admission within the timeframe specified in the Provider/Facility Manual or as otherwise required by law, as failure to give timely notification for emergency admissions will also result in reimbursement penalties of 50% to providers and facilities.

 

Enforcement of the program requirement will lead to greater consistency in our processes. This notice updates Anthem’s UM Program reimbursement penalties and the corresponding sections of the Provider/Facility Manual effective October 1, 2019, to reflect this change to the reimbursement penalty for non-compliance. As a reminder, providers and facilities may not balance bill the member for any such reduction in payment.