New state legislation prompts changes for reimbursement of physician services during credentialing process

Anthem Blue Cross and Blue Shield and our affiliate HealthKeepers, Inc. are working to comply with Virginia legislative House Bill (HB) 139 that became effective July 1, 2018.  If you are a medical doctor (MD) or doctor of Osteopathy (DO) under review to be credentialed for participation in provider networks offered by Anthem and HealthKeepers, Inc., HB 139 will allow you to see Anthem patients and retroactively receive payments if you are ultimately credentialed. 

This means that on or after July 1, 2018, and you are a MD or DO who submits a credentialing application to us, Anthem and HealthKeepers, Inc. will adhere to the requirements specified in HB 139.  Requirements in the bill do not apply to credentialing applications that were submitted BEFORE July 1 but which are still being processed after the July effective date.

 

Under the new law, we are required to establish protocols and procedures for reimbursing MDs and DOs – at the contracted in-network rate – for approved, covered health care services that are provided during the period in which a physician's credentialing application is pending.  Effective July 1 under HB 139, the credentialing period begins with the receipt of a fully 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.’s Anthem HealthKeepers (commercial, non-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.

 

Those 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.

 

• HealthKeepers, Inc.’s Anthem HealthKeepers Plus/FAMIS (Medicaid) health plans

 

• Medicare Advantage health plans

 

Impact to physicians – call to action

 

Hold claims for Anthem members:  During the credentialing period, MDs and DOs should hold claims for our members until Anthem sends a final notification of a credentialing decision.  If you submit claims to Anthem during the credentialing period before receiving a credentialing decision, claims will be rejected 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:  Upon receiving notice of Anthem’s final credentialing approval, MDs and DOs may collect any applicable member cost shares based on members’ health benefit plans as appropriate.  Physicians with approved credentialing applications are required to submit claims under their contract with Anthem and HealthKeepers, Inc.  Those with denied applications, while not obligated to so do, are encouraged to file claims to us on behalf of members to help speed claims processing and payments as appropriate.  As always, we encourage you to verify eligibility and benefits for members via our secure Web-based provider tool – Availity. 

 

Notify Anthem members as required by HB 139:  In order to submit claims pursuant to HB139, MDs and DOs are required to take the following actions regarding members enrolled in health benefit plans offered by Anthem and HealthKeepers, Inc.:

 

• Notify members – either in writing or electronically – stating that the physician’s credentialing application has been submitted to Anthem 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 139. Please refer to the legislation for actual requirements and how they impact you.

 

Questions

 

If you have questions about the status of your credentialing application, please email our credentialing area at credentialing@anthem.com.  All other questions about the credentialing process should be directed to your Anthem network manager.