![]() Physicians with questions are encouraged to contact Anthem Network Relations at a summary of California's unfair payment practices law, see " Know Your Rights: Identify and Report Unfair Payment Practices" More information on timeframes for claim submission can be found in “ Know Your Rights: Timely Filing Limitations” or in CMA health law library document #7511, “ Payment Denials by Managed Care Plans and IPAs.” available free to members on CMA’s Reimbursement Assistance page. As a reminder, California law states plans must allow a minimum of 180 days from the date of service for receipt of a claim for non-contracted providers. Remember, even if a physician fails to submit a claim on time, California law provides a “good cause” exception that requires payors to accept and adjudicate a claim if the physician demonstrates, upon appeal, “good cause” for the delay.Īnthem has clarified that the change does not affect non-contracting physicians. CMA is assessing the issue to determine potential next steps. While the change in Anthem’s claim submission timeframe meets the minimum timeframe allowed by law for contracting physicians, the California Medical Association (CMA) has received several calls from physicians concerned that the June 21 letter of the material contract change was not sufficient advance notice, given the policy change impacts claims with July dates of service.Īs a result of CMA sponsored unfair payment practices law and the resulting regulations, plans are required to provide a minimum of 45 days prior written notice before instituting any changes or amendments about claim submission requirements.ĬMA raised this concern with Anthem, but the payor believes it provided sufficient advance notice. However, as an example, the notice indicates that the change will impact claims with July dates of service if not submitted within 90 days. Under the new requirement, all claims submitted on or after October 1, 2019, will be subject to the new 90 day filing requirement. ![]() Earlier MUE tables are available in the Medicare MUE Archive.Anthem Blue Cross has notified physicians that it is amending sections of its Prudent Buyer Plan Participating Physician Agreement, significantly reducing the timely filing requirement for commercial and Medicare Advantage claims to 90 days from the date of service.Ĭurrently, Anthem requires physicians to submit all professional claims for commercial and Medicare Advantage plans within 365 days of the date of service.Anthem follows the standard of: 90 days for participating providers and facilities. Practitioner Services MUE Table (ZIP) - Effective OctoPosted Sep. Policy Anthem will consider reimbursement for the initial claim, when received and accepted within timely filing requirements, in compliance with federal, and/or state mandates.Facility Outpatient Hospital Services MUE Table (ZIP) - Effective OctoPosted Sep.DME Supplier Services MUE Table (ZIP) - Effective OctoPosted Sep.This includes additions, deletions, and revisions to published MUEs for Practitioner Services, Outpatient Hospital Services, and DME Supplier Services. Quarterly Version Update ChangesĬMS posts changes to each of its NCCI MUE published edit files on a quarterly basis. The confidential status of MUEs is subject to change. An MUE for a Healthcare Common Procedure Coding System (HCPCS) / Current Procedural Terminology (CPT) code is the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service. Not all HCPCS/CPT codes have an MUE.Īlthough CMS publishes most MUE values on its website, other MUE values are confidential. Confidential MUE values are not releasable. National Correct Coding Initiative (NCCI) Medically Unlikely Edits (MUEs) are used by the Medicare Administrative Contractors (MACs), to reduce improper payments for Part B claims. ![]() Medicare NCCI Medically Unlikely Edits (MUEs) Or, call us about InterQual criteria documentation. Visit preauthorization for member information. Visit our medical policies for decision information. If you leave a message outside of those hours, well return your call the next business day. o Anthem assigns the YRH prefix along with the members RID number. Our utilization management staff is available Monday through Friday from 8:00 AM - 6:00 PM.
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