Ethics and Fairness in Carrier Business Practices

Effective July 1, 2019, Anthem Blue Cross and Blue Shield is required to, in the case of a previously authorized medically necessary invasive or surgical procedure, pay claims when there is clinical evidence prompting a less or more extensive or complicated procedure than was previously authorized if the procedure is:

 

• Not investigative in nature, but medically necessary as a covered service under the covered person's benefit plan

 

• Appropriately coded consistent with the procedure actually performed; and

 

• Compliant with our post-service claims process, including required timing for submission.

 

As a reminder, the Virginia Professional Provider Manual specifies the following provision to handle post- service additions to a previously authorized request:

 

The Program’s medical management unit will conduct a Retrospective Review for requests received within 10 business days of the date the Member received the service. If the request for review is received 11 business days or more after the date of service, the provider must submit the claim either electronically or on paper to the post-service claim review unit for adjudication. The claim will be reviewed prior to the claim adjudication. Some claims may be denied for lack of prior authorization pursuant to the provisions of your facility and/or professional contract.

 

Adhering to this provision will ensure that any services not previously authorized are consistent with the type of procedures covered under the previous authorization, are not investigative in nature, and the additional procedure(s) are compliant with the post-service claims process.  Updates to a previously authorized request can be completed by logging into Availity using our Point of Care online tool (http://www.Anthem.com) or by calling Anthem toll free at 1-800-533-1120 to speak to someone in Group Plan Services.