Update to provider/facility UM reimbursement penalties and corresponding update to Provider/Facility Manual

Effective for dates of service beginning October 1, 2019, and after, we will increase the reimbursement penalty for failure to comply with our Utilization Management Program’s pre-certification requirements for services rendered to commercial plan members. Late pre-certifications, and late notices in the case of emergency admissions, are currently subject to a penalty and will be subject to the increase in the penalty.  Failure to comply with Anthem’s pre-certification requirements, and late notice requirements in the case of emergency admissions, will result in a 50% reduction in reimbursement to the provider and facility. 

 

As a reminder, we requires pre-certification prior to the delivery of certain elective services in both the inpatient and outpatient settings. Inpatient claims will remain subject to a 100% penalty/claim denial for non-compliance with pre-certification requirements. For an emergency admission, pre-certification is not required; however, you must notify us of the admission within the timeframe specified in the Provider/Facility Manual or as otherwise required by law, as failure to give timely notification for emergency admissions will also result in a 100% penalty/claim denial to providers and facilities.  If notification occurs 48 hours after the inpatient admission but prior to discharge from the inpatient admission, then the claim may be subject to a 50% penalty to providers and facilities. Claims submitted for high-cost radiology, sleep therapy, and cardiology cases managed by AIM will continue to be subject to a 100% penalty/claim denial to providers and facilities for no pre-certification.

 

Enforcement of the program requirement will lead to greater consistency in our processes. This notice updates Anthem’s UM Program reimbursement penalties and the corresponding sections of the Provider/Facility Manual effective October 1, 2019, to reflect this change to the reimbursement penalty for non-compliance. As a reminder, providers and facilities may not balance bill the member for any such reduction in payment.