Billing members following Medicaid guidelines

Anthem follows Medicaid guidelines and federal regulations regarding billing members.

Providers are prohibited from billing members for any covered service or balance billing for the amount above that is paid by Anthem for covered services.

Anthem members should not pay for physician visits and other medical care when they receive covered services from a provider in their provider network. This means beneficiaries cannot be charged for co-pays, co-insurance, or deductibles.

In addition, you may not bill or charge members a fee for any of the following:

• Failure to timely submit a clean claim with all required information needed for processing:

• 180 day filing deadline for network providers
• 365 day deadline for non-network or emergency transportation providers

• Failure to timely dispute/appeal a claim you believe has not been properly adjudicated:
• Level one claim dispute: 90 days from the date of the EOP
• Level two claim dispute: 30 days from the date of the level one reconsideration decision letter/correspondence
• Failure to appeal a utilization review determination within 30 days of notification of coverage denial
• No-show or cancelled appointments
• The first copy of their medical records

For additional details, review the provider manual https://providers.anthem.com/NV.

If you have questions, please contact Provider Services at 844-396-2330.