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

Anthem Blue Cross and Blue Shield and our affiliate HealthKeepers, Inc. have 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 Anthem and HealthKeepers, Inc., HB822 allows you to see Anthem members and retroactively receive payments if you are ultimately credentialed. 

 

This means that as of July 1, 2020, if you are a provider who already has an executed contract, and submits a completed credentialing application to us, Anthem and HealthKeepers, Inc. will adhere to the requirements specified in HB 822.  If you are a provider entering into a new contract, the effective date will be determined based on the latter of the contract execution date, or the completed credentialing application receipt date.  Requirements in the bill do not apply to credentialing applications submitted BEFORE July 1, but which 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 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.'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 our 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 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 members:  During the credentialing period, providers are required to 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 for the impacted lines of business noted above 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.  However, for lines of business not impacted by legislation, claims submitted before receiving a credentialing decision will process on out-of-network benefits based on the member’s policy.  Submitting claims too early may result in inappropriate payments and member cost shares.

 

Patient financial responsibility:  Upon receiving notice of Anthem'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 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 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 Anthem and HealthKeepers, Inc.:

 

• Notify members – either in writing or electronically – stating that the provider’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 822.  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.

 

Please forward this information to those in your practice who may need this information.

  

610-0920-PN-VA