Changes to our data management system help streamline your demographic update process

Anthem continues to work to enhance our care provider data management system, which should significantly improve your data accuracy, transparency, and experience. In the April 2023 edition of Provider News, we notified our care provider partners about our plans to begin implementing changes to our data management system. Since that time, we’ve continued to include updates and reminders in Provider News. We completed the implementation of these changes in September 2023.

What is important?

• As a reminder, you are contractually required to report any practice changes.
• Tell us when care providers join your group. Notifying us in a timely manner prior to the new care provider rendering care to our members is important.
• Ensure all your contracted care providers’ information is uploaded into our care provider data management system prior to rendering services.
• Claims received for services rendered by a care provider who has not yet been added to your contract will be rejected or processed as out of network.

As we communicated in October, Availity Essentials Provider Data Management (PDM) is the intake application for care providers to submit demographic change requests, including submitting roster uploads. Availity Essentials PDM will replace all current intake channels for demographic change requests and roster submissions as of January 1, 2024. Read the previously published article here.

New group/professional contract requests and provider additions to an existing group/professional contract must be submitted through Provider Enrollment application in Availity Essentials.

What you need to know about billing

As part of this data management system upgrade, Anthem is applying CMS billing guidelines to hold care providers accountable for billing claims data correctly.

Beginning in early 2024, claims submitted using rendering care providers who have not been added to your contract by the date of service billed or with missing or incorrect NPIs will be rejected for more information or processed as out of network.

Other important and helpful reminders

Submitting claims with complete and correct information is critical to ensuring Anthem can process your claims efficiently and accurately:

• Bill according to standard billing guidelines.
• Review your billing practices carefully to ensure the proper TIN, NPI, and rendering care provider information (if applicable) are submitted correctly.
• Bill with an in-state service location.

More information is available online at anthem.com > Providers > Policies, Guidelines & Manuals.

CMS regulations and guidance can be found here.