Post on 13-Feb-2017
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.
HealthKeepers, Inc. Medicaid and MMP Provider Orientation
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.
HealthKeepers, Inc. Medicaid and MMP Provider Orientation
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.
HealthKeepers, Inc. Medicaid and MMP Provider Orientation
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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March 2014 Page 7 of 21
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
HealthKeepers, Inc. Medicaid and MMP Provider Orientation
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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March 2014 Page 9 of 21
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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March 2014 Page 10 of 21
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
HealthKeepers, Inc. Medicaid and MMP Provider Orientation
March 2014 Page 11 of 21
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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March 2014 Page 12 of 21
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).
HealthKeepers, Inc. Medicaid and MMP Provider Orientation
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]
HealthKeepers, Inc. Medicaid and MMP Provider Orientation
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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March 2014 Page 15 of 21
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.
HealthKeepers, Inc. Medicaid and MMP Provider Orientation
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
HealthKeepers, Inc. Medicaid and MMP Provider Orientation
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.