Anthem has been denying codes 98940/98941 as not covered by this provider type. We have reached out to Anthem executives about this issue and sent several examples to them. Anthem has informed us that they have identified the system issue that was causing these denials. All impacted claims have been pulled for reprocessing. Providers should see reimbursement for these services in the next 30-45 days.
Anthem has also been denying 97140 manual therapies. We have been discussing this issue with them and believed this issue was resolved. However, providers have stated this may not be the case. Be sure you are using modifier 59 and this is being done in an area separate than the adjustment. Also, providers must point their diagnosis codes to the procedure being performed. We will continue working on this issue.
Some providers received letters stating they were at least 20% higher than the 2019 mean number of visits per patient for the Anthem Chiropractic network in Kentucky. We are reaching out to Anthem executives for more information on this letter and to get more clarification as to how these numbers were derived.
As I am sure you are aware by now, Anthem has removed the requirement for prior authorization for physical medicine services performed in a chiropractic office. You can read their statement here. However, providers have had multiple other issues arise since the first of the year. Two of the major complaints have been denials for E/M services and denials for manual therapy. We have sent claim examples to them and are awaiting a response.
As you are hopefully aware, Anthem is planning on starting a new pre-authorization process for all therapy services, 97xxx codes, on March 1st. This process will require you to register with AIM for pre-certification of these services.
The KAC has had the stance from the beginning of this process that Anthem has not notified providers properly of this change. According to KRS 304-17A-235 a material change to a contract is defined as any change that will create a significant increase in administrative cost. Applying this new pre-authorization process is a significant increase in the administrative burden on a provider and thus this material change should be distributed to all providers in an orange envelope as required in KRS 304-17A-235.
The KAC has had many conversations with Anthem through this process. Anthem was willing to listen to our concerns and was helpful in providing information on the upcoming change. Ultimately we could not come to an agreement that the orange envelope notification was required. This led the KAC to meet with the Department of Insurance (DOI) and ask for their opinion on this issue.
Today we have received word from DOI that they have informed Anthem that the previous notifications of the new AIM process are not sufficient to meet the criteria of KRS 304.17A-235. Anthem has been instructed to not implement the AIM precertification until proper notification has been sent.
At this point, we have not heard from Anthem on their plan going forward, but we should be receiving a notification that the March 1st implementation date of AIM for Doctors of Chiropractic should be delayed. Please keep your eyes open for more information as we receive it. We know this is a significant and alarming change. We are continuing to work with Anthem toensure that your voice is heard about the impact of this change on your practice.
We would like to take a moment and thank you for your continued membership in the KAC. The KAC has a dream. A dream that all chiropractors are successful in helping their patients achieve health. Working together we have been able to take a step closer to this dream. Your membership allowed us to accomplish this delay and hopeful change in Anthem’s policy.
Anthem Pre-Authorization Change (Update)
Here are the details:
- Anthem is implementing preauthorization for all 97XXX codes starting March 1st, 2020. This is a directive from Anthem corporate and they are implementing for all provider types.
- You may have received a postcard directing you to read the December provider update. We do not believe this is sufficient notification for providers and have told Anthem that we believe they are in violation of Kentucky law. The KAC believes this type of change falls under Kentucky’s Orange Envelope Law and requires a 90-day notice before implementation can occur.
- We are working closely with Anthem to find a solution, as we believe this will negatively impact patient access and add administrative costs to our doctors.
- At this time, we are not asking for any doctor or patient involvement but keep your eyes open for communication from the KAC.
If you have received rejections from Anthem for missing pre-authorization of a 97XXX code, please remove all patient information and email it to Dr. Nick Payne at email@example.com
Anthem has stated that all therapy codes will need prior authorization starting March 1, 2020, through AIM. This notice was sent out in their Provider News on 12/1/2020. At this time, no provider we have spoken with has received notice in accordance with the “Orange Envelope Law”. The KAC continues to work with Anthem to find a solution to this new process.