Update to Provider UM reimbursement penalties and corresponding update to Provider Manual*

Effective for dates of service beginning October 1, 2019, and after, Anthem Blue Cross and Blue Shield (Anthem) will increase 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 and will be subject to the increase in the penalty.  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 the Provider and Facility. 

 

As a reminder, 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 timeframe specified in the Provider Manual or as otherwise required by law, as failure to give timely notification for emergency admissions will also result in reimbursement penalties of 50% to providers and facilities.

 

Enforcement of the program requirement will lead to greater consistency in our processes. This notice updates Anthem’s UM program reimbursement penalties and the corresponding sections of the Provider Manual effective October 1, 2019, to reflect this change to the reimbursement penalty for non-compliance. As a reminder, Providers and Facilities may not balance bill the member for any such reduction in payment.

* Notice of Material Changes/Amendments to Contract and Changes to Prior Authorization Requirements may apply for new or updated reimbursement policies, medical policies, or prior authorization requirements.