Update to provider utilization management reimbursement penalties for professional providers

Effective for dates of service on and after July 17, 2021, Anthem Blue Cross and Blue Shield (Anthem) will begin to apply the reimbursement penalty for failure to comply with the utilization management (UM) program’s prior authorization requirements for services rendered to commercial plan members. Late prior authorizations, and late notices in the case of emergency admissions, are currently subject to a penalty as outlined in the Anthem Virginia Professional Provider manual. 

 

The late notification penalty has been outlined in the Provider Manual since September 2, 2019.  However, due to system migrations, the late notification penalty has not been applied.  Failure to comply with Anthem’s prior authorization requirements, and late notice requirements in the case of emergency admissions, will result in a 50% reduction in reimbursement to professional providers.  Facilities and behavioral health providers are not impacted at this time. Other exceptions may apply. 

 

IMPORTANT REMINDERS:

 

• Anthem requires prior authorization prior to the delivery of certain elective services in both the inpatient and outpatient settings. For an emergency admission, prior authorization is not required. However, you must notify Anthem of the admission within the time frame specified in the Provider Manual or as otherwise required by law.  Failure to give timely notification for emergency admissions will also result in reimbursement penalties of 50% to Professional Providers.

 

• Professional providers may NOT balance bill the member for any such reduction in payment.

 

Going forward, enforcement of the program requirements will lead to greater consistency in our business processes.

 

1163-0621-PN-VA