*Only GLMS members and their staff are eligible to participate. For information on GLMS membership, call 502-736-6324
Recent Payer Updates:
Anthem Provider Newsletter March 2019
In January, Anthem, Inc. announced that it’s accelerating the launch of IngenioRx, its new pharmacy benefits manager (PBM), which will serve members of all Anthem’s affiliated health plans. We will begin moving some members to IngenioRx in the second quarter (Q2) of 2019, and we will continue the transition, in waves, with the majority of members moving in the latter part of 2019 and the first quarter of 2020. More on this and other topics of interest can be found in the March Provider Newsletter here.
Anthem Update regarding E/M with modifier 25 - Professional
Anthem Blue Cross and Blue Shield (Anthem) has identified that providers often bill a duplicate Evaluation and Management (E/M) service on the same day as a procedure even when the same provider (or a provider with the same specialty within the same group TIN) recently billed a service or procedure which included an E/M for the same or similar diagnosis. The use of modifier 25 to support separate payment of this duplicate service is not consistent with correct coding or Anthem’s policy on use of modifier 25. Beginning with claims processed on or after March 1, 2019, Anthem may deny the E/M service with a modifier 25 billed on the day of a related procedure when there is a recent service or procedure for the same or similar diagnosis on record. If you believe a claim should be reprocessed because there are medical records for related visits that demonstrate an unrelated, significant, and separately identifiable E/M service, please submit those medical records for consideration. https://providernews.anthem.com/kentucky/article/notice-of-material-changesamendments-to-contract-and-prior-authorization-changes-february-2019
Anthem Lab Fee Reductions effective 9/25/18
Anthem mailed letters to providers on June 26, 2018 notifying them of reductions in lab fees effective 9/25/18 along with an updated list of rates. "The Anthem Blue Cross and Blue Shield PPO, HMO and POS fee schedules will be updated for services provided on or after September 25, 2018,* as identified on the enclosed document showing the new rates. As a reminder, drugs (J Codes) are updated on a quarterly basis as we receive new allowances and are priced at ASP+6%. HCPC codes are updated as part of an annual fee schedule notice if there are changes. If you have additional questions on specific codes or need further information, please contact your Network Relations Consultant at l-800-205-5870 or go to www.Avality.com to check code allowances electronically."
United Healthcare - The March 2019 Network Bulletin from United Healthcare has been posted online and the items below are included in this issue.
Humana Claim Payment Inquiry Resolution Guide
To simplify claim payment inquiries, Humana has worked to clarify its process and to ensure that you have the support you need. Attached is the updated resolution guide.
• Page 1 - Information about making claim-payment inquiries and disputing determinations
• Page 2 - Description of Humana’s Provider Payment Integrity (PPI) team’s inquiry and escalation processes
• Page 3 - Contact information pertaining to PPI inquiries and grievances and appeals
• Page 4 - Tools that can help you improve coding accuracy