Anthem HealthKeepers Medicare-Medicaid Plan (MMP),

a Commonwealth Coordinated Care Plan Provider Orientation

       

March 2014

HealthKeepers, Inc. is an independent licensee of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. AVAPEC-0261-14

Provider Orientation Table of Contents

Anthem HealthKeepers Medicare-Medicaid Plan (MMP) ............................................................. 2

Reference Tools .............................................................................................................................. 2

Your Responsibilities ...................................................................................................................... 3

Fraud, Waste and Abuse ................................................................................................................. 4

Ongoing Credentialing .................................................................................................................... 4

Cultural Competency ...................................................................................................................... 5

Translation Services ........................................................................................................................ 5

Access and Availability Standards .................................................................................................. 6

Member Enrollment ........................................................................................................................ 7

Anthem HealthKeepers MMP Eligibility and Enrollment .............................................................. 7

Verifying Eligibility ........................................................................................................................ 8

Downloading Your Panel Listing ................................................................................................... 9

Precertification and Notification ..................................................................................................... 9

Our Service Partners ..................................................................................................................... 12

Pharmacy Program ........................................................................................................................ 14

Submitting Claims ........................................................................................................................ 14

Grievances and Appeals ................................................................................................................ 16

Care Management and Interdisciplinary Care Team (ICT) .......................................................... 19

Disease Management .................................................................................................................... 19

Quality Management ..................................................................................................................... 20

Maternal Child Services ................................................................................................................ 20

Community Involvement .............................................................................................................. 21

HealthKeepers, Inc. Medicaid and MMP Provider Orientation

March 2014 Page 2 of 21

Anthem HealthKeepers Medicare-Medicaid Plan (MMP)

Effective April 1, 2014, HealthKeepers, Inc. will participate in the Commonwealth Coordinated

Care (CCC) Dual Demonstration program. The program integrates care and reimbursement for

dual-eligible individuals who are enrolled in both Medicare and Medicaid. Through one

Medicare-Medicaid Plan (MMP), dual-eligible members have full access to their Medicaid and

Medicare benefits. The integration of the program is governed by a three-way agreement with

the Centers for Medicare and Medicaid (CMS), the Virginia Department of Medical Assistance

Services (DMAS) and HealthKeepers, Inc.

HealthKeepers, Inc. will offer Anthem HealthKeepers Medicare-Medicaid Plan (MMP), a

Commonwealth Coordinated Care plan for who reside in one of five regions: Central Virginia,

Northern Virginia, Tidewater, Western/Charlottesville and Roanoke. See the Anthem

HealthKeepers MMP Eligibility and Enrollment section for member eligibility requirements and

effective dates for each region.

Reference Tools

Provider website

Our provider website is available to all providers. The tools located on this site allow you to

perform many common authorization and claims transactions, check member eligibility, update

information regarding your practice, manage your account, access our new reimbursement

policies, and more. As a participating provider, you can submit precertification requests and

claims using the site.

Register as a user on our provider website, Point of Care, available 24 hours a day, 7 days a

week. The Anthem HealthKeepers MMP provider website is available 24 hours a day, 7 days a

week and contains online tools and resources to assist providers caring for Anthem

HealthKeepers MMP members.

Your Support System

As a member of the HealthKeepers, Inc. network, you are supported by many different

departments as you provide care for our members:

Our Provider Relations team offers hands-on services and training to primary care providers

(PCPs) and specialists. We provide customer-focused services related to clinical and

administrative aspects of care.

Our Medical Management program provides precertification services, hospital concurrent

review, discharge planning and case management.

HealthKeepers, Inc. has many specialized teams to help you with your claim questions. Our

partners in Provider Services offer assistance with any claim issues, member enrollment,

questions and general inquiries.

Medicaid provider: Call our Provider Services team at 1-800-901-0020, Monday to Friday,

8 a.m.-6 p.m., Eastern time.

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March 2014 Page 3 of 21

Anthem HealthKeepers MMP providers: Call our Anthem HealthKeepers MMP Customer

Service team at 1-855-817-5788, Monday through Friday, 8 a.m.-8 p.m., Eastern time.

Additional Resources

For information about Medicaid and Medicare, visit the Centers for Medicare & Medicaid

Services (CMS) website.

For information about National Committee for Quality Assurance (NCQA) guidelines, visit

the NCQA website.

For health plan information, visit the Virginia DMAS website.

Your Responsibilities

For most products, we assign each member a PCP and we send both members and their PCPs

reminders to make preventive care appointments. As a participating provider, you have certain

responsibilities in getting members the care they need, including:

Providing services to your patients without any discrimination whatsoever

Notifying us when you reach a full panel and are no longer accepting any new patients.

Stressing the importance of an advance directive for your patients

Working with us to meet professionally accepted, state and national standards of care; we

regularly analyze our performance in all types of care our members receive – including

medical, behavioral health and long-term care – against state and national benchmarks, and

we’ll help you identify areas needing improvement and work with you to meet those

standards

We’re here to help. Read more about your responsibilities in your provider contract or call us if

you need assistance. Anthem HealthKeepers MMP providers, refer to the Anthem HealthKeepers

MMP provider manual for a complete list of responsibilities.

We designed our policies to promote compliance with the Americans with Disabilities Act.

You’re required to remove any existing barriers and accommodate the needs of members with

disabilities. Your office should have:

Street-level access

An elevator or accessible ramp into the facility

Access to a lavatory that accommodates a wheelchair

Access to an examination room that accommodates a wheelchair

Clearly marked, reserved parking for people with disabilities, unless street-side parking is

available

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March 2014 Page 4 of 21

We offer a comprehensive case management program to help coordinate care for members with

chronic illnesses and behavioral health needs. Pregnant moms are risk-assessed and enrolled in

high-risk obstetrics case management as appropriate. See page 16 of this guide for Maternal

Child Services information.

Fraud, Waste and Abuse

Fraud, waste and abuse are barriers to our members’ care and deplete medical resources and our

state partners’ valuable financial resources. At HealthKeepers, Inc., we are vigilant in our efforts

to prevent this drain of resources.

Our Corporate Investigations Department identifies aberrant billing patterns and investigates

allegations of fraud and abuse. This department works with the state and other health care

companies to detect and stop abuses in the health care system.

How can you help?

Always confirm the patient’s identity

Ensure the services you render are necessary, completely documented in the medical records

and billed appropriately

If you suspect or witness fraud, waste, or abuse, tell us immediately:

Call the Fraud & Abuse phone line at 1-800-368-3580, Monday to Friday, 8 a.m.-6 p.m.,

Eastern time; Anthem HealthKeepers MMP providers, call Customer Service at 1-855-817-

5788, Monday to Friday, 8 a.m.-8 p.m., Eastern time

– Contact your Provider Services representative

– Read more about reporting fraud, waste and abuse in your provider contract; Anthem

HealthKeepers MMP providers, read more about reporting fraud, waste and abuse in the

Anthem HealthKeepers MMP provider manual

Ongoing Credentialing

Periodically, you may receive requests from us for documents required for ongoing

credentialing. These documents may include updated disclosure of ownership forms, updated

licensure or updated malpractice insurance face sheets. Additionally, you may receive requests

from credentialing related to expired information or changes in licensure.

Recredentialing occurs every three years or sooner if required by state law. Providers are also

responsible for notifying HealthKeepers, Inc. if there is any change in your licensure, specialties

or other practice information to ensure we can maintain accurate records. You can contact

Provider Services or log in to update your information.

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March 2014 Page 5 of 21

We participate in the Council for Affordable Quality Healthcare (CAQH) collaborative. You can

submit an application using the CAQH Universal Credentialing DataSource application.

Anthem HealthKeepers MMP providers should review the credentialing/recredentialing

requirements outlined in the Anthem HealthKeepers MMP provider manual.

Cultural Competency

HealthKeepers, Inc. fosters a strong cultural competency within our company as well as our

provider networks. By practicing strong cultural competency, you:

Acknowledge the importance of culture and language

Embrace cultural strengths with people and communities

Assess cross-cultural relations

Understand cultural and linguistic differences

Strive to expand cultural knowledge

Cultural barriers between you and your patients can:

Impact your patient’s level of comfort; this may increase fear of what you, the provider,

might find upon examination

Result in a different understanding of our health care system

Cause a fear of rejection of your patient’s personal health beliefs

Impact your patient’s expectation of you and of the treatment plan

Visit our Cultural Competency Training program for additional information.

Translation Services

Telephonic interpreter services are available to members by calling Member Services at

1-800-901-0020 for Medicaid providers and 1-855-817-5787 for Anthem HealthKeepers MMP

providers. These services are available 24 hours a day, 7 days a week.

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March 2014 Page 6 of 21

Access and Availability Standards

It’s our responsibility to make sure our members have access to primary care services for routine,

urgent and emergency services and specialty care services for chronic and complex care. We

make sure our providers respond to members in a timely manner for the need or request by

conducting telephonic surveys to confirm providers are meeting these standards.

Appointment Standards

You must arrange to provide care as expeditiously as the member’s health condition requires and

according to each of the following appointment standards:

Appointments for emergency services shall be made available immediately upon the

member’s request.

Appointments for urgent medical conditions shall be made within 24 hours of the member’s

request.

Appointments for routine, primary care services shall be made within 30 calendar days of the

member’s request. This standard does not apply to appointments for routine physical

examinations, regularly scheduled visits to monitor a chronic medical condition if the

schedule calls for visits less frequently than once every 30 days, or routine specialty services

like dermatology, allergy care, etc.

For maternity care, providers must offer initial prenatal care appointments for pregnant members

as follows:

First trimester – within 14 calendar days of request

Second trimester – within 7 calendar days of request

Third trimester – within 3 business days of request

Appointments must be scheduled for high-risk pregnancies within three business days of

identification of high risk to the provider or immediately if an emergency exis

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Member Enrollment

Reimbursement is contingent upon proof of member enrollment.

Our member ID cards

Medicaid

FAMIS

Anthem HealthKeepers MMP Eligibility and Enrollment

HealthKeepers, Inc. members eligible for the dual demonstration include adult, full-benefit dual

eligible members who are:

Entitled to benefits under Medicare Part A and enrolled in Medicare Part B and D

Eligible for full Medicaid benefits

Elderly or Disabled with Consumer Direction (EDCD) and HIV/AIDS waiver participants

Residing in nursing facilities; some individuals residing in assisted living facilities qualify

Live in the demonstration service area

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March 2014 Page 8 of 21

MMP Member Cards

Implementation of the dual demonstration will be rolled out in two phases; first, voluntary and

then passive by region.

Voluntary enrollment is when eligible members proactively elect to enroll in the program

Passive enrollment is when eligible members do not opt-out of the program and are

automatically enrolled

Region and enrollment timelines

Phase Regions Voluntary

Enrollment

Passive

Enrollment

1a Central/Richmond

(with exception of phase 1c counties and cities)

April 1, 2014 August 1, 2014

1b Tidewater

(with exception of phase 1c counties and cities)

April 1, 2014 July 1, 2014

1c Central and Tidewater Regional areas:

Counties: Stafford, Lancaster, Middlesex,

Spotsylvania, Northumberland, Prince Edward,

Westmoreland, Mecklenburg, James City County

and Northampton and York

Cities: Fredericksburg and Williamsburg

May 1, 2014

(pending network

adequacy review)

August 1, 2014

(pending

network

adequacy

review)

2 Western/Charlottesville, Northern Virginia

and Roanoke

June 1, 2014 October 1, 2014

Verifying Eligibility

Use our Eligibility Lookup tool to get the most up-to-date member information. To check

eligibility, log in and select Eligibility under Tools > Eligibility & Panel Listings.

You can also call the automated Provider Inquiry Line at 1-800-901-0020 to verify member

eligibility.

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Anthem HealthKeepers MMP providers log in or call Customer Service at 1-855-817-5788 to

check member eligibility.

Downloading Your Panel Listing

Online member panel lists are run and posted to the website as of the day prior to make available

the most current information about members assigned to PCPs. You can find panel listings by

logging in and selecting Claims > Eligibility & Panel Listings > PCP Member Listings. You can

also call Provider Services at 1-800-901-0020 to obtain a copy of your panel listing.

Anthem HealthKeepers MMP providers log in and view and/or download provider panel listings

online.

A member can change his or her PCP assignment by calling Member Services at

1-800-901-0020 for Medicaid and 1-855-817-5788 for Anthem HealthKeepers MMP.

Precertification and Notification

Precertification is required for:

All inpatient elective admissions

Nonemergency facility-to-facility transfer

Select nonemergent outpatient and ancillary services

Precertification is required for all home health care services (skilled nursing visits, speech

therapy, physical therapy, occupational therapy, social workers and home health aides). Home

health aides must be under supervision of a registered nurse or physical therapist.

Precertification is not required for:

In-office specialty services

Evaluation and management-level testing and procedures

Emergency room visits or observation

Home health care evaluations

Physical therapy evaluations provided at outpatient facilities

Visit the Coverage & Clinical UM Guidelines, and Precertification Requirements page for

additional information regarding services requiring precertification or notification. If our medical

director denies coverage, the attending provider will have an opportunity to discuss the case with

him or her. We will mail a denial letter to the hospital, the member’s PCP and the member with

information on the member’s appeal and fair hearing rights and process.

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Our medical management clinician coordinates members’ discharge planning needs with:

The hospital utilizations review/case management staff

The attending physicians – the attending physician will coordinate follow-up care with the

member’s PCP and the PCP will contact the member to schedule it

For ongoing care, we work with you to plan discharges to appropriate settings, including:

Hospice facilities

Convalescent facilities

Home health care programs (e.g., home I.V. antibiotics)

Skilled nursing facilities

For members who are hospitalized, our care management nurses will also work with the

members, utilization review team and PCPs or hospitals to develop discharge plans of care and

link the members to:

Community resources

Our outpatient programs

Our Disease Management Centralized Care Unit (DMCCU)

Our Maternal Child Health Case Management program

Is Precertification Required?

Use our Precertification Lookup tool to:

Determine if a service needs a precertification

Find additional information regarding precertification for DME, vision, transportation and

other ancillary services

Search by your market, the product of the member and the CPT code. If you don’t know the

exact code, you can also search by description.

Precertification Requests

You can submit precertification requests:

By fax to 1-800-964-3627

By calling Provider Services at 1-800-901-0020

Electronically by logging in and selecting Precertification

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Anthem HealthKeepers MMP providers can request precertification requests:

Online

By fax to:

1-800-964-3627for initial inpatient admissions

1-800-505-1193 for behavioral health outpatient services

1-877-434-7578 for behavioral health inpatient services

1-888-280-3725 for therapies, home health, durable medical equipment and discharge

planning

1-888-280-3726 for concurrent review clinical documentation for inpatient

By calling Customer Service at 1-855-817-5788

You must provide the precertification nurse with appropriate information for the Anthem

HealthKeepers MMP member.

The servicing provider or the hospital must provide clinical documentation for medical necessity

review.

Precertification response time frames:

Urgent, nonemergent requests:

FAMIS – 24 to 48 hours

Medallion – 24 to 72 hours

Medicare-Medicaid Plan (MMP) – 72 hours

Emergency requests: No precertification required

Routine care requests:

FAMIS – 2 days from the date all information is received, but not to exceed 14 days

Medallion – 14 days

Medicare-Medicaid Plan (MMP) – 14 days

Hospital Precertification Requirements

Emergency room visits:

No precertification is required.

Notify us within 48 hours or the next business day if a member is admitted to the hospital

through the emergency room.

Emergent admissions:

Network hospitals must notify us within one business day of emergent admission.

Documentation must be complete; we’ll ask the hospital for additional necessary

documentation.

Our medical management staff will verify eligibility and determine coverage.

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Inpatient elective admissions:

We require precertification of all inpatient elective admissions and notification of all

deliveries/births.

On the day of admission, you must notify us by phone or fax that the member has arrived

as scheduled.

Throughout the inpatient stay, a concurrent review nurse will review and authorize the

additional coverage as needed.

For hospital precertification requests, the referring PCP or physician can submit the request:

By fax to 1-800-964-3627

By calling Provider Services at 1-800-901-0020

Electronically by logging in

Submit precertification requests with all supporting documentation immediately upon identifying

the inpatient request or at least 72 hours prior to the scheduled admission. This will allow us to

verify benefits and process the precertification request.

For services that require precertification, we make case-by-case determinations that consider the

individual’s health care needs and medical history in conjunction with nationally recognized

standards of care.

Precertification Status

Providers and hospitals can check the status of precertification requests by logging in to the

provider website and clicking Precertification > Forms and other resources, or calling Provider

Services at 1-800-901-0020 for Medicaid or 1-855-817-5788 for Anthem HealthKeepers MMP

to speak with an agent.

Anthem HealthKeepers MMP providers can log in to check precertification status online.

Our Service Partners

Lab Services

Notification or precertification is not required if lab work is performed by a HealthKeepers, Inc.

preferred lab vendor (e.g., LabCorp and their approved subsidiaries).

Lab work not performed by LabCorp requires precertification (e.g., lab tests performed in the

physician’s office that are not on the Physician Office Lab list or lab tests performed at a

participating hospital outpatient department that does not hold a subcontract with LabCorp).

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March 2014 Page 13 of 21

Some lab tests on the Physician Office Lab list may require authorization. Remember, you can

use the Precertification Lookup tool to determine if precertification is required.

All testing sites are required to be in compliance with the Clinical Laboratory Improvement

Amendment (CLIA) and have certificates, waivers, or high accreditation as appropriate for the

specific lab test performed.

Other Service Partners

In addition to lab services, we partner with other service vendors to offer additional support to

our members, including the following dental, vision and radiology services:

Anthem HealthKeepers Plus (Medallion and FAMIS) Service Providers:

American Specialty Health (ASH) – Chiropractic benefit 1-877-327-2746

Davis Vision 1-800-773-2847

LogistiCare 1-877-892-3988

American Imaging Management (AIM) Radiology 1-800-714-0040

Nonemergent transportation services are available for Medicaid members only.

Health Service Reviews are currently required for the following AIM services*:

Computer tomography (CT/CTA) scans

Nuclear cardiology

Magnetic resonance (MRI/MRA)

Positron emission tomography (PET) scans

*We will notify you if/when procedures are added to this list.

Anthem HealthKeepers MMP Service Providers

Dental Services DentaQuest 1-800-341-8478

www.dentaquestgov.com

Vision Services Davis Vision [insert number & web

address]

Nonemergent Transportation LogistiCare [insert number & web

address]

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March 2014 Page 14 of 21

Pharmacy Program

HealthKeepers, Inc. contracts with Express Scripts (ESI).

Submitting Claims

We encourage you to submit your claims on our website or use Electronic Data Interchange (EDI)

but we also accept paper claims. Paper claims cannot be physically altered; they cannot include

strikeovers, ink strikethroughs or changes made with correction fluid, or they will be rejected.

We give you several options to submit claims electronically.

Submit both CMS-1500 and UB-04 claims by logging in. Select the claims menu and choose

the appropriate claim form.

Submit 837 batch files and receive reports through the website at no charge. You must

register for this service first.

Submit claims electronically by using a clearinghouse via EDI. Using our electronic tool helps

reduce claims and payment processing expenses and offers:

Faster processing than paper

Enhanced claims tracking

Real-time submissions directly to our payment system

HIPAA-compliant submissions

Reduced claim rejections

Reduced adjudication turnaround time

Paper claims:

Submit a properly completed claim for all services performed or items/devices provided to:

HealthKeepers, Inc.

Attn: Claims

P.O. BOX 27401

Richmond, VA 23279

Ensure all required information is included

Don’t alter or change any billing information (e.g., using white out, crossing out, writing

over mistakes, etc.); altered claims will be returned to the provider with an explanation of the

reason for the return

Remember: there are designated, critical fields on both the CMS 1500 and 1450 claim forms.

We will not accept handwritten critical fields if the claim contains any computer generated or

typed data. Fields not identified as critical may contain handwritten data if it was added for

the first time. HealthKeepers, Inc. will also accept claims from those providers who submit

entirely handwritten claims.

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Timely filing guidelines

For both participating and nonparticipating providers, timely filing is 365 calendar days.

Clear Claim Connection

Clear Claim Connection is a tool available to help you determine if you will be reimbursed for

services based on the procedure codes and modifiers you billed on your claim. This tool only

provides guidance for code combinations you wish to submit on your claims; it does not

guarantee claim payment.

You can access this tool by logging in to the provider self-service site and selecting Claims >

Clear Claim Connection under Forms & Other Resources.

Electronic Payment Services

We encourage you to enroll in Electronic Funds Transfers (EFTs) and Electronic Remittance

Advices (ERAs).

Enrolling in EFT/ERA gives you the benefit of:

Receiving ERAs and importing the information directly into your practice management or

patient accounting system

Routing EFTs to the bank account of your choice

Creating your own custom reports within your office

Access to reports 24 hours a day, 7 days a week

You will receive information on how to enroll in EFT and ERA in a separate mailing from the

clearinghouse partner.

Providers delivering care for commercial and Medicaid patients will:

Receive separate remittances for HealthKeepers, Inc. (Medicaid) and commercial services

Begin receiving a second EFT payment for HealthKeepers, Inc. (Medicaid) services with the

prefix 33 – you do not need to do anything additional to continue receiving EFT payments

Rejected or Denied?

While we want every submitted claim to pay the first time it’s submitted, this isn’t always the

case. You may get a notice that your claim was rejected or denied. So what’s the difference?

Rejected claims

A rejected claim does not enter our system at all for one or more of the following reasons:

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March 2014 Page 16 of 21

National Provider Identification (NPI) number is invalid

Provider address is invalid

Claim was physically altered (e.g., with correction fluid) or handwritten

Claim was rejected by the clearinghouse

Denied claims

A denied claim goes through the adjudication process and is denied for payment for reasons,

including one or more of the following:

Member not enrolled on the date of service

CPT or HCPCS codes were invalid

Wrong claim form was used

No authorization obtained for the date of service

The Explanation of Payment (EOP) will explain the reasons for the denial.

If your claim is rejected, you will receive a document ID number as a reference, not a unique

claim number as you would receive with a denied claim.

Routine Claim Inquiries

For routine claim inquiries, your call will be handled by a specially trained call agent in our

Provider Services Unit (PSU) as part of our Provider Experience Program. This program was

setup to ensure provider claim inquiries are handled efficiently and timely while maximizing

resolution at the point of call. Agents have the ability to answer your claims-related questions as

well as adjust a small set of routine claim types

When you call our National Customer Care center with a claims inquiry, your call is directed to

an agent trained to address the issue over the phone. When that isn’t possible, the agent will

coordinate resolution with the appropriate departments including our Internal Resolution Unit

(IRU). The IRU coordinates the research, error correction and adjustment of your claims as

appropriate. If a delay is anticipated due to the complexity of a claim, you will receive

notification of the delay along with a new target date for resolution.

Grievances and Appeals

Grievances

A grievance is your expressed dissatisfaction about any matter except a payment dispute or a

proposed adverse medical action. A grievance can be submitted by any physician, hospital,

facility or other health care professional licensed to provide health care services.

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March 2014 Page 17 of 21

Examples of grievances may include issues with a member panel list, your contract or rate, our

authorization process, an associate’s behavior, or even a member’s behavior.

HealthKeepers, Inc. tracks all provider grievances until they are resolved. If you disagree with

the resolution, you can escalate your grievance to a higher level.

Appeals

Provider appeals involve issues regarding reimbursement to health care providers for medical

services already provided.

Provider Appeals to the Department of Medical Assistant Services (DMAS): If a provider

rendered services to a member enrolled in a Medicaid program and was either denied

reimbursement for the services or received reduced reimbursement, that provider can request an

appeal of the denied or reduced reimbursement. Before appealing to DMAS, Managed Care

Organization (MOC) providers must first exhaust all MCO appeal processes.

Refer to the appeals chart for definitions and the appropriate process to use.

Medical Appeals

There are separate and distinct appeal processes for our members and providers, depending on

the services denied or terminated. Refer to the denial letter issued to determine the correct

appeals process.

To initiate the appeal process for a medical necessity or experimental/investigational adverse

decision, please send your written appeal request with all supporting documentation to the

following address within either 15 months of the date of service or 180 days of the date of the

adverse determination notice, whichever is later. HealthKeepers, Inc. will resolve and respond in

writing to all standard appeal requests within 30 calendar days from the initial date of receipt of

the appeal. Send written appeals to:

HealthKeepers, Inc.

Attn: Grievances and Appeals

P.O. Box 27401

Richmond, VA 23279

Provider Appeal Process for Medical Necessity and Experimental/Investigational Adverse

Decisions

HealthKeepers, Inc. will resolve and respond in writing to all standard appeal requests within 60

calendar days.

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March 2014 Page 18 of 21

Payment Disputes

There are two types of denials: administrative and medical. Administrative denials include

improper coding, no authorization on file for the dates of service or the number of services

exceeds the authorized services.

Use Clear Claim Connection for guidance when you submit a claim and to understand why a

claim is denied. If you still do not understand why the claim was denied or if you would like to

have the denial researched, Medicaid providers can contact Provider Services at 1-800-901-0020

to speak with an agent; MMP providers call Customer Service at 1-855-817-5788 . Our agents

are trained to research and, if possible, adjust your claim during the phone call.

CPT code changes or errors should be stamped (not handwritten) with the words Corrected

Claim and resubmitted. If you need to resubmit a corrected claim, attach a copy of the EOP

showing the denial. Claims must have the EOPs with the original claim numbers for review of

administrative appeals.

Under the Patient Protection and Affordable Care Act, we cannot pay for services rendered by

any provider located outside the United States and its territories. Those claims will be denied.

To file a payment dispute with HealthKeepers, Inc., go to the appeals chart for the appropriate

process to use. Submit all payment disputes with a copy of the EOPs and letters of explanation to

HealthKeepers, Inc. at

[HealthKeepers, Inc.

Attn: 27401

Richmond, VA 23279]

Anthem HealthKeepers MMP appeals or claim disputes that are the result of contractual issues

between the provider and HealthKeepers, Inc. carry no member liability, and the member is

held harmless for any payment. It is important to follow the directions in the denial letter issued

to ensure the proper appeals process is followed. Administrative complaints/payment disputes

must be filed within 120 calendar days of the initial decisions. Anthem HealthKeepers MMP

providers submit provider liability appeals/payment disputes to:

Provider Liability Appeals/Payment Disputes

HealthKeepers, Inc.

P.O. Box 61599

Virginia Beach, VA 23466

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March 2014 Page 19 of 21

Provider Appeal Process for Resolution of Billing Disputes

HealthKeepers, Inc. will resolve and respond in writing to all billing disputes within 30 calendar

days for Medicaid and 45 calendar days for Anthem HealthKeepers MMP.

Care Management and Interdisciplinary Care Team (ICT)

For Anthem HealthKeepers MMP, each member has a care manager and an Interdisciplinary

Care Team (ICT) that provides person-centered coordination and care management for members.

The ICT team consists of:

The member and/or his or her designee

Designated care manager

Primary care physician

Behavioral health professional

The member’s home care aide or Long Term Services and Supports (LTSS) provider

Other providers as requested by the member or his/her designee or as recommended by the

care manager or primary care physician and approved by the member and/or his/her designee

The ICT facilitates coordination between the health plan and all the providers for the delivery of

the member’s medical services and benefits. A care plan is developed for the member to receive

the most appropriate services and available community resources. The care plan is evaluated and

updated to reflect changes as the member’s health status changes.

The member is an important part of the team and involved in the planning process. The

member’s participation is voluntary, and they can choose to decline at any time. The case

manager is the coordinator of the team and reaches out to providers and other team members to

coordinate the needs of the member. Important information about the member including the

assessment and care plan details is available by logging in to our secure provider website. Health

care practitioners and providers of care in the home or community are also very important

members of the team and help to establish and execute the care plan.

Disease Management

Our Disease Management program is an integrated, member-centric care management program.

Care managers focus on all the needs of the member.

Each member enrolled in Disease Management receives a tailored plan of care and intervention

based on his or her clinical acuity and individual needs. As appropriate, telephone calls are made

by a licensed nurse or social worker to the member, guardian or physician to determine progress

and the need for further intervention. Other members receive health improvement mailings.

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We have several programs for your patients, including:

Asthma

Bipolar disorder

Congestive heart failure

Coronary artery disease

Chronic obstructive pulmonary disease

(COPD)

Diabetes

HIV/AIDS

Major depressive disorder

Obesity

Schizophrenia

Transplant

Many of these programs are accredited by the National Committee for Quality Assurance

(NCQA).

Our Disease Management department serves as a partner to you by:

Providing member education and creative solutions for overcoming barriers to obtaining care

Communicating pertinent information back to you

Soliciting your input for care planning

Quality Management

Clinical Quality Management works to ensure we provide access to quality health care and

services. They continually analyze provider performance and member outcomes for

improvement opportunities. Our solutions are focused on improving the quality of clinical care,

increasing clinical performance, offering effective member and provider education, and ensuring

the highest member and provider satisfaction possible.

Maternal Child Services

Obstetrical Precertification and Notification Coverage Guidelines

You must notify HealthKeepers, Inc. as follows:

At the first prenatal visit

Within 24 hours of delivery with newborn information. Please include:

Baby’s date of birth

Disposition at birth

Gender

Weight in grams

Gestational age

When it comes to our pregnant members, we are committed to keeping both mom and baby

healthy. That’s why we encourage all our moms-to-be to take part in our New Baby, New Life

program, a comprehensive case management and care coordination program that offers:

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Individualized, one-on-one case management support for women at the highest risk

Care coordination for moms who may need a little extra support

Educational materials and information on community resources

Incentives to keep up with prenatal and postpartum checkups and well-child visits after the

baby is born

We partner with providers and moms to ensure all medical and resource needs are met, aiming

for the best possible outcomes for both moms and babies.

Community Involvement

HealthKeepers, Inc. is committed to ensuring our members have adequate access to quality care

and health education. We work in partnerships with schools and community-, government- and

faith-based organizations. We organize and participate in events throughout the state. We offer

education and community outreach and information sessions on HealthKeepers, Inc. benefits and

services.