Provider claim payment disputes for Anthem’s Commercial lines of business
As a reminder, unlike inquiries about claims status, provider disputes, or requests for additional information, provider claim payment disputes occur after a claim is finalized, and a provider disagrees with the claim payments Anthem has issued. Some examples include claim disputes regarding manual processing errors, contract interpretation, reduced payments, code editing issues, Other Health Insurance denials, eligibility issues, timely filing issues *, and so forth.
Anthem’s streamlined provider claim dispute process utilizing Availity across all Anthem lines of business, allows a more cohesive and efficient approach for providers when:
- Filing a claim payment dispute.
- Sending supporting documentation to Anthem.
- Checking the status of a claim payment dispute.
- Viewing the history of a claim payment dispute.
*Reminder: we will consider reimbursement of a claim that has been denied due to failure to meet timely filing if you can:
- provide documentation that the claim was submitted within the timely filing requirements
- demonstrate good cause exists.
Reminder on how the provider claim payment dispute process works
For Anthem, the provider claim payment dispute process consists of the following:
Commercial Claims Payment Dispute: A written notice to Anthem challenging, appealing, or requesting reconsideration of a claim or clinical determination that has been denied, adjusted, contested, or seeking resolution of a contract dispute; or disputing a request for reimbursement of an overpayment of a claim.
Providers may submit the claim payment dispute in writing effective November 20, 2021, via Availity; providers are encouraged to submit all commercial disputes via Availity.
When submitting a claim payment dispute for commercial claims, please include as much information as you can including but not limited to the following:
- A clear explanation of the basis for which the Provider or Facility believes the payment amount should be
- Whether the request for reimbursement is for the overpayment of a claim, contest, denial, adjustment, or other action
Please refer to the Provider Manual for additional details.
Anthem will issue a written determination stating the pertinent facts and explaining the reasons for its determination within 60 working days after the date of receipt of the dispute.
Submitting commercial claim payment disputes in writing
When submitting a claim payment dispute in writing, providers must include the Claim Information/ Adjustment Request Form and submit to:
Submitting claim payment disputes via Availity — preferred method, as of November 20, 2021
For step-by-step instructions to submit a claim payment dispute through Availity:
- Log into Availity at availity.com.
- Select Help & Training | Find Help.
- Under Contents, select Overpayments and Appeals.
- Select Dispute a Claim.
Through Availity, you can upload supporting documentation and receive immediate acknowledgment of your submission.
Anthem’s review and providers’ other options
Anthem will review the claim payment dispute once received and communicate an outcome in writing or through the Availity Portal. Providers can check the status of a claim payment dispute on the Availity portal at any time.
Once the claim payment dispute is submitted, the decision is final. A claim payment dispute may not be submitted through the provider appeals department (Grievance and Appeals) again. Please refer to the Provider Manual for additional information.
To learn more about the claim dispute tool, register for a live webinar:
- Log in to Availity and select Help & Training | Get Trained.
- Select Sessions and go to Your Calendar to locate a webinar.
- Select View Course and then select Enroll.
- The Availity Learning Center will email you with instructions to attend.
As always, providers can refer to the Provider Manual, as the manual includes additional information about inquiries, and the provider claim dispute process.
November 2021 Anthem Provider News - Nevada