Dispute resolution process for care providers

Navigating the dispute resolution process can be challenging for care providers. It involves understanding both the administrative and legal procedures necessary to resolve disputes with Anthemeffectively, whether for Commercial or Medicaid claims. Below is a comprehensive guide based on key documents, outlining how to manage these disputes and what resources you will need.

Resource links

Availity Essentials access:

• Availity Essentials: Care providers can handle claims, status inquiries, medical necessity appeals, and other processes at Availity Essentials.

Sections to reference via Availity Essentials:

• Claims & Payments: For claims submissions, attachments, and status inquiries, navigate to this section after logging in.
• My Providers: Access the Provider Data Management within Availity Essentials to manage roster submissions and verify TIN/business name.

Provider manuals

Commercial provider manual:

• Access link: Commercial Provider Manual
• Relevant sections:
  
  • Section I: acceptance of digital ID cards
  • Section II: eligibility and benefit inquiry and response
  • Section IV: claims submissions, attachments, and status
  • Section V: remittances and payments, electronic funds transfer

Medicaid provider manual:

• Access link: Medicaid Provider Manual
• Relevant sections:
  
  • 42 CFR § 438.106: compliance and coverage details
  • Nevada Medicaid Service Manual § 105.3: Medicaid‑specific service and claims information

For additional assistance, providers can contact Provider Services via the number on the back of our member ID card. Use the provided links and references to navigate claims and administrative processes effectively. Make sure you have the latest version of the provider manuals available on https://www.anthem.com/nv/provider for the most updated policies and guidelines.

Administrative and legal dispute procedures

1. Provider administrative denial:

• Definition: Occurs when a claim or service is denied for non-medical necessity reasons, such as late notification or lack of recertification.

2. Provider administrative appeal procedure

• Filing an appeal:
  • Submit a written request with supporting documentation.
  • Appeals must be filed within 60 calendar days of the administrative denial notice.
    • Submission methods: Use https://Availity.com or mail to Anthem's Appeals Department:

Administrative Appeals Address:
Anthem Blue Cross and Blue Shield
Healthcare Solutions Appeals Department
P.O. Box 62429
Virginia Beach, VA 23466‑2429

Payment Appeals Address:
Anthem Blue Cross and Blue Shield
Healthcare Solutions Payment Appeals
P.O. Box 61599
Virginia Beach, VA 23466‑1599

• Response time: Anthem will communicate a decision within 30 calendar days.
• Outcome: An upheld decision includes a letter detailing the right to request a State Fair Hearing.

3. Provider grievance procedures

• Filing a grievance:
• Express dissatisfaction with Anthem services, separate from medical necessity denials.
• Submit in writing to the Anthem Provider Grievance Department.
• Resolution time: Grievances are resolved within 90 calendar days.
• Response: Expect a conclusion letter with findings and disposition.

4. Provider payment disputes:

• Initiating a payment appeal:
• Dispute issues such as payment amounts or authorization denials.
• File via Availity Essentials for digital acknowledgment or submit detailed writings.
• Second‑Level Appeal: If unresolved, submit in writing within 30 calendar days of the first‑level decision.

5. Using Availity for disputes:

• Digital submission:
• Log into Availity, access Claims & Payments, select Claim Status, and use the Dispute button.
• Upload necessary documentation for your claim dispute.

6. Provider state fair hearing process:

• Eligibility and filing:
• Care providers can request a hearing after exhausting Anthem’s internal dispute process.
• Requests must be submitted within 90 calendar days of the denial notice.

Sources of information:

• These procedures are documented in the Anthem Blue Cross and Blue Shield provider manuals for both Commercial and Medicaid services.
• Further clarification is available through resources like Anthem’s website and provider services support.

Important highlights and nuances:

• Timeliness: Strict adherence to deadlines for appeals and grievances is crucial.
• Documentation: Comprehensive and clear documentation is essential for every appeal or grievance.
• Choice of process: It is vital to differentiate between administrative appeal processes and grievance procedures based on the nature of the issue.
• Use of Availity Essentials: Use Availity Essentials for streamlined digital submissions and tracking of disputes.