1 Abortion Health Benefit Plan Coverage* MH Provider Facility - - PDF document

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1 Abortion Health Benefit Plan Coverage* MH Provider Facility - - PDF document

Jan 09, 2024 266 likes •323 views

David Tucker EDI Strategic Planning Director David.Tucker@Anthem.com 1 One of the largest US health benefits companies ~ 67 million individuals served through its affiliated companies > 36 million members enrolled in our affiliated

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David Tucker EDI Strategic Planning Director David.Tucker@Anthem.com

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 One of the largest US health benefits companies

  • ~ 67 million individuals served through its affiliated companies
  • > 36 million members enrolled in our affiliated health plans

1 in 9 Americans receives medical coverage through a WellPoint company

NY

 Supports the 270/271 and 276/277 transactions  CORE Seal for CAQH Phase I and II  Supports HIPAA X12 TR3, CAQH CORE and BCBSA

requirements

 Supports Real Time and Batch transactions from

Trading Partners, Direct Connects and Web Portal (Availity) transactions

 Available 24h/6 days (Monday – Saturday) per week

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4 Abortion Health Benefit Plan Coverage* MH Provider Facility – Inpatient Psychiatric - Inpatient Ambulatory Serv Center Facility Home Health Care MH Provider Fac – Outpatient Psychiatric - Outpatient Anesthesia Hospice MRI/CAT Scan Psychotherapy Cardiac Rehabilitation Hospital Newborn Care Radiation Therapy Chemotherapy Hospital - Ambulatory Surgical Obstetrical Routine Physical Chiropractic Hospital - Emergency Accident Obstetrical/Gynecological Screening Laboratory Dental Care Hospital - Emergency Medical Occupational Therapy Screening X-ray Diagnostic Lab Hospital – Inpatient Oral Surgery Second Surgical Opinion Diagnostic Medical Hospital – Outpatient Pediatric Skilled Nursing Care Diagnostic X-Ray Immunizations Pharmacy Speech Therapy Dialysis Infertility Physical Medicine Substance Abuse Durable Med Equipment (DME) In-vitro Fertilization Physical Therapy Substance Abuse Fac – Inpatient DME Purchase Mammogram, HR Patient Physician Visit – Office: Sick Substance Abuse Fac – Outpat DME Rental Mammogram, LR Patient Physician Visit – Office: Well Surgical Emergency Services Maternity Podiatry Surgical Assistance Family Planning Medical Prof (Physician) Visit - Home Urgent Care Flu Vaccination Mental Health (MH) Prof (Physician) Visit - Inpatient Vision (Optometry) General Benefits Health Benefit Plan Coverage Prof
  • f (Physician) Visit – Office**
Well Baby Care Gynecological MH Provider – Inpatient Prof (Physician) Visit –Outpatient MH Provider – Outpatient *accounts for 86%, **accounts for 2%

 Returns Patient Liability  Certification Indicator

  • UM contact information

 PCP (Primary Care Physician)  Other Payer Information

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  • Co-insurance
  • Copayments
  • Deductible
  • Out of Pocket
  • Benefit Limitations and

Maximums

  • Remaining Amounts

 270/271Volumes

  • 1.5 million per day
  • 86% are general benefit (STC 30)
  • 2% are office visit (STC 98)
  • All other STC account for less than 1%

 276/277 Volumes

  • Over 300,000 per day
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 Meet with Trading Partners and Providers to

discuss resolve 27x concerns and future enhancements (bi-weekly, monthly, quarterly)

 Wisconsin Providers Include:

  • Luther Hospital
  • University Wisconsin Medical Foundation (UWMF)

 Clearinghouse/Vendor Includes:

  • Passport
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 Grea

eate ter Deta tail/G il/Gra ranula lari rity ty within in 277 Claim im Statu tus

  • Requesting Medical Records
  • Investigating Other Insurance
  • Aligning with the 835 CARC/RARC

 2014 Enhancem

emen ents ts for 271 Eligibi ibility lity Respo ponse se

  • Patient’s actual cancel date when patient is inactive for date of

service being requested

  • Health Insurance Exchange (HIX) patient’s grace period

information

  • Patient’s HRA amount/remaining
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 Governance

  • Launching a robust Governance process to ensure

greater consistency and granularity across all Plans

 Industry Participation and Collaboration

  • Soliciting additional input and feedback in case any
  • ther entity would like to engage in collaborative

discussions

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 Increase adoption and expand Provider usage

  • f 27x Electronic Transactions.

 Enhance transaction detail, availability and

quality towards minimization of Provider abrasion and unnecessary phone calls

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