CurrentAnthemPolicy G-10002

Reimbursement Policy Sanctioned Providers

Defines Anthem HealthKeepers' reimbursement stance for providers who are excluded or debarred from state and federal healthcare programs; applies to providers submitting claims to the plan for Virginia HealthKeepers/Anthem HealthKeepers Plus Medicaid products.

Policy Summary

PayerAnthem

PolicyReimbursement Policy Sanctioned Providers

Policy CodePolicy G-10002

Change TypeClarified; administrative updates

Effective Date12/30/2024

Next Review DateN/A

Key ActionClaims submitted by providers who are excluded or debarred from state or federal healthcare programs will be denied unless contracts or requirements indicate otherwise.

SourceLink

POLICY UPDATE CHANGES

Policy language clarifies that the health plan does not allow reimbursement to providers excluded or debarred from participation in state and federal healthcare programs, including for emergency services.

Policy template updated on 12/27/2022 and language updated to remove 'Reimbursement of and Opt-Out' from the title.

12/30/2024 review approved and effective with no changes.

1primary reimbursement stance (deny sanctioned providers)

VAstate product listed

2013-2024policy history years

CMS/OIG/CFR/Statesource authorities

Reimbursement Criteria

Reimbursement Criteria for Sanctioned Providers

Stance on reimbursement for services by sanctioned providers:

No reimbursement for sanctioned providers: Services rendered by providers who are excluded or debarred from participation in state and federal healthcare programs will not be allowed for reimbursement.

Denial of claims submitted by sanctioned providers: Claims received for services submitted by sanctioned providers will be denied unless provider, state, federal, or CMS contracts and/or requirements indicate otherwise.

Screening requirement: The health plan screens providers through all applicable state and federal exclusion lists to identify sanctioned providers.

Emergency services: Services rendered, including emergency services, by sanctioned providers will not be allowed for reimbursement unless contracts or regulatory requirements indicate otherwise.

Policy Summary

PayerAnthem

PolicyReimbursement Policy Sanctioned Providers

Policy CodePolicy G-10002

Change TypeClarified; administrative updates

Effective Date12/30/2024

Next Review DateN/A

Key ActionClaims submitted by providers who are excluded or debarred from state or federal healthcare programs will be denied unless contracts or requirements indicate otherwise.

SourceLink

On This Page

Coding expectationsmixed

Standard correct coding applies; use CPT, HCPCS, revenue codes as appropriate and supported by documentation

Documentation support requirement

Documentation support requirementServices billed must be fully supported in the medical record and/or office notes (use CPT, HCPCS, and/or revenue codes as appropriate).

Coding and billing standardsUse proper industry-standard compliant codes on all claim submissions (CPT, HCPCS, revenue codes).

Authorization and medical necessityServices must meet authorization and medical necessity guidelines appropriate to the procedure, diagnosis, and member's state of residence.

Consequences of noncomplianceIf coding/billing guidelines or policies are not followed, the plan may reject or deny the claim, recover/recoup payment, or adjust reimbursement.

Applicability to provider typesUnless otherwise noted, reimbursement policies apply to both participating and non-participating professional providers and facilities.

Provider Actions and Billing Guidance

Denial Risk

Do not bill for services from excluded or debarred providers

Claims submitted by providers who are excluded or debarred from participation in state or federal healthcare programs will be denied unless provider, state, federal, or CMS contracts and/or requirements indicate otherwise. The health plan screens providers against all applicable state and federal exclusion lists; services rendered by sanctioned providers, including emergency services, will not be allowed for reimbursement.

Denied claims: Services billed by excluded/debarred providers will be denied absent applicable contracts or regulatory requirements.
Provider screening: The plan screens providers through all applicable state and federal exclusion lists.
Emergency services: Reimbursement is not allowed for emergency services rendered by sanctioned providers unless contracts/requirements indicate otherwise.

Key Definitions

Provider excluded or debarred (sanctioned/excluded provider)

DefinitionProvider excluded or debarred from participation in state and federal healthcare programs (sanctioned/excluded provider).

Reimbursement stanceThe health plan does not allow reimbursement to providers who are excluded or debarred from participation in state and federal healthcare programs.

Claims handlingClaims submitted by sanctioned providers will be denied unless provider, state, federal, or CMS contracts and/or requirements indicate otherwise.

ScreeningThe health plan screens providers through all applicable state and federal exclusion lists to identify sanctioned providers.

Emergency servicesServices rendered, including emergency services, by sanctioned providers will not be allowed for reimbursement unless other contracts/requirements override this policy.

OpenPayer

Reimbursement Policy Sanctioned Providers

Reimbursement Criteria

Coding and Documentation Expectations

Provider Actions and Billing Guidance

Key Definitions