New state legislation prompts changes in reimbursement of services during credential process: Medicaid clarification
Please note, this communication applies to Anthem HealthKeepers Plus and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) offered by HealthKeepers, Inc.
HealthKeepers, Inc. has implemented necessary requirements to comply with Virginia legislative House Bill (HB) 822 that became effective July 1, 2020. If you are a new provider applicant under credentialing review for participation in provider networks offered by HealthKeepers, Inc., HB 822 will allow you to see Anthem HealthKeepers Plus members and Anthem CCC Plus members and retroactively receive payments if you are ultimately credentialed.
This means that as of July 1, 2020, if you are a provider who submits a completed credentialing application to us, HealthKeepers, Inc. will adhere to the requirements specified in HB 822. Requirements in the bill do not apply to credentialing applications submitted before July 1, 2020, but only to applications that are still in the credentialing review process after the July effective date.
Under the new law, we are required to establish protocols and procedures for reimbursing new provider applicants at the contracted in-network rate for approved, covered services provided during the period in which a provider’s credentialing application is pending. Effective July 1, 2020, under HB 822, the credentialing period begins with the receipt of a completed credentialing application. Incomplete credentialing applications and denied applications are excluded.
What lines of our business are impacted?
Members enrolled in the following health benefit plans are impacted by the new state legislation:
- Anthem's PAR/PPO health benefit plans.
- HealthKeepers, Inc. (including commercial and Medicaid) health benefit plans. This includes health plans members purchase on or off the Health Insurance Marketplace (commonly referred to as the exchange).
- Commonwealth of Virginia COVA Care and COVA HDHP health benefit plans, the Local Choice (TLC) health benefit plans, and the Line of Duty (LODA) health benefit plans.
- Medicare Supplement health benefit plans.
The lines of business not impacted are:
- Blue Cross and Blue Shield Service Benefit Plan (also called the Federal Employee Program or FEP).
- Administrative services only (ASO) health plans.
- Medicare Advantage health plans.
Impact to providers – call to action
Once the effective date is determined, the effective date will apply to all lines of business; however, based on the line of business, claims will process differently.
Hold claims for Anthem HealthKeepers Plus members:
During the credentialing period, providers are required to hold claims for our members until HealthKeepers, Inc. sends a final notification of a credentialing decision. If you submit claims to HealthKeepers, Inc. during the credentialing period before receiving a credentialing decision, claims for the impacted lines of business noted above will be rejected or denied indicating that the claims must be resubmitted upon a final credentialing decision. Members will be protected from inappropriate billing and held harmless during this period.
Patient financial responsibility:
Except for the Anthem HealthKeepers Plus program with Medallion and Anthem CCC Plus program, upon receiving notice of HealthKeepers, Inc.'s final credentialing approval, providers may collect any applicable member cost shares based on members' health benefit plans as appropriate. Providers with approved credentialing applications are required to submit claims under their contract with HealthKeepers, Inc. For denied applications, no claims will be paid for services rendered on behalf of Anthem HealthKeepers Plus members, and providers may not bill any Anthem HealthKeepers Plus members for any outstanding balances.
Notify Anthem HealthKeepers Plus members as required by HB 822:
In order to submit claims pursuant to HB 822, providers are required to take the following actions regarding members enrolled in health benefit plans offered by HealthKeepers, Inc.:
- Notify members – either in writing or electronically – stating that the provider’s credentialing application has been submitted to HealthKeepers, Inc. and is under review.
- Provide the notice in advance of providing treatment to members.
- Include in the notice to members certain credentialing information as outlined in HB 822. Please refer to the legislation for actual requirements and how they impact you.
If you have questions about the status of your credentialing application, please email our credentialing area at email@example.com. All other questions about the credentialing process should be directed to your Anthem HealthKeepers Plus network manager.
Please forward this information to those in your practice who may need this information.
If you have any questions about this communication, call Provider Services at 1‑800‑901‑0020 or Anthem CCC Plus Provider Services at 1‑855‑323‑4687.
January 2021 Anthem Provider News - Virginia