Anthem Blue Cross and Blue Shield (Anthem) reimbursement policies for Ohio Medicaid became effective February 1, 2023 and are located on the Anthem provider website.

 

For dates of service (DOS) that span prior to February 1, 2023, the legacy Paramount Medicaid policies will apply for members who are transitioning to Anthem for their Medicaid coverage. For any claim whose DOS starts prior to and ends after February 1, 2023, providers will continue to use Paramount Medicaid policies. The legacy Paramount reimbursement policies can be found at https://www.paramounthealthcare.com/services/providers/reimbursement-policies.

 

Anthem reimbursement policies apply to providers who serve members enrolled in Anthem with dates of service on or after February 1, 2023, and are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal, or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, Anthem strives to minimize these variations. To view the Anthem reimbursement policies for Ohio Medicaid, visit the provider self‑service website at https://providers.anthem.com/oh.

 

What does this mean to me?

Refer to the reimbursement policy websites, your respective provider manual, and/or your respective provider contract as a guide for reimbursement criteria. Reimbursement policies serve as a guide to assist you in accurate claim submissions and to outline the basis for reimbursement if the service is covered by a member’s benefit plan. The determination that a service, procedure, item, etc. is covered under a member's benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member’s state of residence. Proper billing and submission guidelines are required along with the use of industry-standard, compliant codes on all claim submissions.  

 

Reimbursement policies undergo reviews for updates to state contracts, rules, and requirements, as well as federal and CMS requirements. Additionally, updates may be made at any time if we are notified of a mandated change or due to an Anthem business decision. We reserve the right to review and revise our policies when necessary. When there is an update, we will publish the most current policy at https://providers.anthem.com/oh.

 

Code and clinical editing

Anthem applies code and clinical editing guidelines to evaluate claims for accuracy and adherence to accepted national industry standards and plan benefits. We use sophisticated software products to ensure compliance with standard code edits and rules. These products increase consistency of payment for providers by ensuring correct coding and billing practices. Editing sources include but are not limited to CMS National Correct Coding Initiative, Medical Policies, and Clinical Utilization Management Guidelines. Anthem is committed to working with you to ensure timely processing and payment of claims.

What if I need assistance?

The complete set of policies are available at https://providers.anthem.com/oh. If you have questions, visit the provider self-service website. You may also contact your Anthem Provider Experience consultant.

 

If you have legacy Paramount reimbursement policy questions related to claims prior to and/or spanning past February 1, 2023, contact a Paramount Provider Services representative or call 419-887-2535 or 800‑891‑2542.

 

Reimbursement policies

Refer to the complete list of reimbursement policies on the reimbursement policy website, your provider manual, and/or your provider contract. These policies apply unless provider, federal, or CMS contracts and/or requirements indicate otherwise.

 

Policy topic

Category

Abortion (Termination of Pregnancy)

Surgery

Assistant at Surgery Guidelines (Modifier 80/81/82/AS)

Coding

Claim Requiring Additional Documentation

Administration

Claim Submission — Required Information for Facilities

Administration

Claim Submission — Required Information Professional

Administration

Claims Timely Filing

Administration

Claims with Charge Discrepancies

Administration

Code and Clinical Editing Guidelines

Administration

Consultations

Evaluation and Mangement

Corrected Claims

Administration

Diagnoses Used for DRG Computation

Coding

Distinct Procedural Services (Modifiers 59, XE, XP, XS, XU)

Coding

DME Modifiers for New, Rented, and Used Equipment

DME and Supplies

Documentation Standards for Episodes of Care

Administration

DRG Inpatient Facility Transfers

Facilities

DRG Newborn Inpatient Stays

Facilities

Drug Screen Testing

Laboratory

Drugs and Injectable Limits

Drugs

Duplicate Services on the Same Date of Service

Administration

Durable Medical Equipment (Rent to Purchase)

DME and Supplies

Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)

Prevention

Eligible Billed Charges

Administration

Emergency Services: Non-Participating Providers and Facilities

Administration

Facility Take-Home DME and Medical Supplies

DME and Supplies

Global Surgical Package

Surgery

Hysterectomy

Surgery

Inpatient Readmissions

Facilities

Locum Tenens Physicians

Administration

Maternity Services

Surgery

Maximum Units Per Day

Administration

Medical Recalls

Administration

Modifier 24: Unrelated E&M Service

Coding

Modifier 25: Significant, Separately Identifiable E&M Service by the Same Physician on the Same Day of the Procedure or Other Service

Coding

Modifier 26 and TC: Professional and Technical Component

Coding

Modifier 62: Co-Surgeons

Coding

Modifier 63: Procedure on Infants less than 4kg

Coding

Modifier 78: Return to OR for Related Procedure during the Postoperative Period

Coding

Modifier 90: Reference (Outside) Laboratory and Pass-Through Billing

Coding

Modifier 91: Repeat Clinical Diagnostic Laboratory Test

Coding

Modifier LT/RT: Left Side/Right Side Procedures

Coding

Modifier Usage

Coding

Multiple and Bilateral Surgery: Professional and Facility Reimbursement

Coding

Multiple Delivery Services

Surgery

Multiple Procedure Payment Reduction

Medicine

Multiple Radiology Payment Reduction

Radiology

Nurse Practitioner and Physician Assistant Services

Administration

Portable/Mobile/Handheld Radiology

Radiology

Preadmission Services for Inpatient Stays

Facilities

Preventable Adverse Events

Administration

Preventive Medicine and Sick Visits on Same Day

Evaluation and Management

Professional Anesthesia Services

Anesthesia

Prosthetics and Orthotics Devices

Prosthetics and Orthotics

Reimbursement for Items under Warranty

Administration

Reimbursement for Reduced and Discontinued Services

Coding

Requirements for Documentation of Proof of Timely Filing

Administration

Reimbursement of Sanctioned Providers

Administration

Robotic Assisted Surgery

Surgery

Scope of Practice

Administration

Sexually Transmitted Infections — Testing

Laboratory

Sterilization

Surgery

Transportation Services: Ambulance and Non-Emergent Transport

Transportation

Unlisted, Unspecified, or Miscellaneous Codes

Coding

Vaccines for Children (VFC) Program

Prevention


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February 2023 Anthem Provider News - Ohio