Prior Authorization & Claims

MMP Reimbursement Policies

We want to assist physicians, facilities and other providers in accurate claims submissions and to outline the basis for reimbursement if the service is covered by a member’s Anthem Blue Cross Cal MediConnect Plan (Medicare-Medicaid Plan) benefit plan. Keep in mind that determination of coverage under a member’s benefit plan does not necessarily ensure reimbursement. These policies may be superseded by state, federal or CMS requirements. Providers and facilities are required to use industry standard codes for claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The billed code(s) should be fully supported in the medical record and/or office notes. Industry practices are constantly changing and Anthem Blue Cross reserves the right to review and revise its policies periodically.

Reimbursement Policy Disclaimer

These policies serve as a guide to assist you in accurate claim submissions and to outline the basis for reimbursement if the service is covered by a member’s Anthem Blue Cross Cal MediConnect Plan (Medicare-Medicaid Plan) benefit plan. The determination that a service, procedure, item, etc. is covered under a member's benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis as well as to the member’s state of residence. You must follow proper billing and submission guidelines. You are required to use industry standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities.

If appropriate coding/billing guidelines or current reimbursement policies are not followed, Anthem Blue Cross (Anthem) may:

• Reject or deny the claim
• Recover and/or recoup claim payment

Anthem reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider or state contracts, or state, federal or CMS requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, Anthem strives to minimize these variations.

Anthem reserves the right to review and revise its policies periodically when necessary. When there is an update, we will publish the most current policy to this site.

• General Reimbursement Policy Definitions