Anthem Blue Cross and Blue Shield in Maine continues to manage workflow challenges that have caused delays in our ability to properly process and pay claims to some providers. To support you during this time, we have established a team dedicated to Maine healthcare providers. Effective immediately, this team can be reached during regular business hours (8:30 a.m. to 5 p.m. EST) by calling: 1-833-690-2936.

To stay up to date on information or changes that may affect claims processing in the future, we urge you to sign up to receive important updates by email.  

In the meantime, we would like to answer some questions we know are on your mind:

Why is this happening?

System Modernization

In August, Anthem in Maine upgraded to a new provider data management system called Strategic Provider 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 be 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 are currently working to reprocess 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 direct outreach to providers whose claims are not processing properly. For more information, please refer to the communications we provided in June and October.

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 uses analytics to identify billing patterns that fall outside expected parameters, which is common across the industry as this practice is generally effective.

However, upon review, we found some claims for health services identified by this program were consistent with the level of service provided. On the whole, we believe this program is an effective way to help ensure healthcare services are billed, coded and reimbursed appropriately. However, for the time being, we have paused the program. Further, we recognize that specialized care for behavioral health does not always align with this program, and applicable codes will be excluded going forward.

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 Availity, 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 Availity, 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.
• 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.

Where can you go for help?

If you need assistance:

• Live Chat: Availity Chat with Payer is available during regular business hours (9 a.m. to 5 p.m.). 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: Maine providers can contact the dedicated team for assistance during regular business hours (8:30 a.m. to 5 p.m. EST) by calling a dedicated phone line: 1-833-690-2936.
• 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. 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.

Thank you.

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