Wiki Issues with Anthem processing claims incorrectly

[pchamp25]

I am in need of help regarding our facility claims processing incorrectly with Blue card Anthem plans. I work at an ASC located in NH and per our contract w/Anthem NH, along w/Anthem's reimbursement policy, all of our facility claims need to be submitted on a CMS1500 form. This makes all the Blue card plans process our claims as professional and no matter what we do, we can't get these to reprocess correctly. We dispute with copies of our contract with Anthem NH along with Anthem's reimbursement policy but to no avail. We have even had out Anthem reps help but they are now advising us since it is out of state plans, they can't control how the claim is processed in the end. I feel as this is a known problem and is due to how Anthem NH set up their system so all claims are submitted on CMS1500 forms, we should get help from Anthem NH for the out of state plans that are not processing our claims correctly. We are now having to get patients involved which is not easy and VERY time consuming.
Has anyone come across a problem like this? If so, how did you handle it? Was there any resolution?
We are pulling our hair out doing appeal after appeal after appeal with no resolution and in the end not getting paid!

Any help or information on how to handle this problem would be much appreciated!

TIA

 

[CBLENNIE]

Are you appending modifier SG - Ambulatory surgical center (ASC) facility service, to each CPT & HCPCS code submitted on the HCFA form? I work for a Blue plan and if we received a HCFA claim with a CPT and/or HCPCS code with modifier SG attached to the codes we would consider the claim as a facility claim not a professional claim.

 

[pchamp25]

Are you appending modifier SG - Ambulatory surgical center (ASC) facility service, to each CPT & HCPCS code submitted on the HCFA form? I work for a Blue plan and if we received a HCFA claim with a CPT and/or HCPCS code with modifier SG attached to the codes we would consider the claim as a facility claim not a professional claim.

Yes all of our claims have modifier SG appended to all CPT & HCPCS codes which is why it is frustrating they are processing our claims as a professional claim, and not a facility

 

[CBLENNIE]

Yes all of our claims have modifier SG appended to all CPT & HCPCS codes which is why it is frustrating they are processing our claims as a professional claim, and not a facility

Well Jiminy Crickets, I don't know what more you can do to get these claims processed correctly by the Home Blue plans. Sorry...

 

[cottentail]

So I had the same problem with Cigna MedB Adv plans. They would process the physician claim, and then recoup their claim to pay the facility. The ASC was getting paid at the physician rate. After months of frustration and back and forth, I believe I found the solution. In box #24J (rendering provider NPI), we would put the Facility's NPI and all of a sudden we started getting the correct reimbursement. I hope that helps.

 

[pchamp25]

So I had the same problem with Cigna MedB Adv plans. They would process the physician claim, and then recoup their claim to pay the facility. The ASC was getting paid at the physician rate. After months of frustration and back and forth, I believe I found the solution. In box #24J (rendering provider NPI), we would put the Facility's NPI and all of a sudden we started getting the correct reimbursement. I hope that helps.

Thank you! We will give this a try!