Effective November 12, 2004:
Anthem, Inc. will cover Mental Health and Social Skills therapy services for
persons with any Autism Spectrum Disorder (ASD) on parity with medical benefits,
in all of Anthem’s commercial, private healthcare insurance plans in Colorado.
These
changes in Anthem’s commercial plans coverage were initially negotiated by an
Anthem subscriber member — a mother for her son with ASD — in order to obtain a
higher level of coverage (on parity with medical benefits coverage) for mental
health services and social skills therapy, including Relationship Development
Intervention (RDI™) therapy.
An
Advocate’s Blueprint:
This
was first accomplished by challenging Anthem’s narrow interpretation of two
prior Colorado statutes: the first statute defined autism as a neurobiological
(medical) disorder and mandated commercial, private health insurance plans in
Colorado to pay for speech and occupational and physical therapy services under
that subscriber’s medical benefits. The second statute defined six
“biologically-based mental illnesses” and mandated that all commercial private
health insurance plans in Colorado must pay for the mental health care of these
six major mental illnesses on parity with medical illness.
The
next challenge was to get Anthem to implement a system-wide change, such that
Anthem would agree to provide this higher-level of mental health, social skills
and RDI™ therapy coverage (at the same level as the plans’ medical benefits
coverage) to ALL Anthem subscriber members for persons with ASD — in ANY of
Anthem’s commercial private health insurance plans. This is a major
breakthrough in coverage for persons with ASD diagnoses with Anthem insurance. Anthem
is Colorado’s largest private health insurance carrier, and, since their recent
merger with WellPoint in November 2004, they are now the largest private health
insurer in the nation.
Don’t
have Anthem Insurance?
Although
this announcement specifically pertains to families with any Anthem commercial,
private health insurance plan, those of you with other Colorado private
commercial carriers (i.e., Sloan’s Lake, United Healthcare, Aetna, etc.) or
those of you who have a self-insured, self-funded, federal or ERISA plans,
should also read this alert. It would be possible, for those of you without
Anthem commercial plans to use this information to contact your own insurance
carriers and challenge their lesser coverage issues in this same way. With this
change in Anthem’s coverage, you should be able to effectively argue that this
(recent) precedent-setting change in Anthem’s coverage (for all mental health
services, social skills and RDI™ therapies for persons with ASD) should now be
similarly covered under your own insurance plans. Currently, federal plans and
self-insured plans that use Anthem as the third-party payor to pay
claims are technically exempt from complying with Colorado statute because the
employer is the one who actually pays out the money to cover the claims, and
not the insurance company. However, you could readily cite this new decision on
the commercial side of Anthem as a precedent for trying to obtain the same
kinds of changes implemented in Anthem’s federal/ERISA/self-funded plans.
What
does this mean to you?
First
you should determine if you have a private, commercial Anthem plan. You can
contact your employer’s human resource department or call the Anthem customer
service number on your insurance card to find out your type of plan.
For
those of you who currently have private commercial Anthem insurance plans, you
should act promptly to get reimbursement for all of your 2004 claims. The law
requires Anthem to pay for claims submitted within 12 months of the date of
service. Act now or lose your opportunity to collect on claims, which started
in January 2004.
After you have followed the process (below) for submitting
all your 2004 claims, you should then take action on older claims.
Specifically, if you had Anthem commercial insurance at some time during the
period from 2000 through 2003, (Anthem merged with Blue Cross Blue Shield of
Colorado in 2000), gather together the same types of MH/SS/RDI™ claims for possible
reimbursement back to you by Anthem. As we do not yet know the process for
this, please contact Sarony Young at Family Voices of Colorado (303-973-5780)
for information. Right
now, submit only the 2004 invoices/claims.
Here
is the process to submit your 2004 Anthem claims:
NOTE:
KEEP COPIES OF EVERYTHING YOU SEND TO YOUR INSURER!
1.
Collect all of the 2004 billing invoice/claims (for both “in-network” and
“out-of-network” providers) that you have paid for mental health, social skills
and RDI™ therapy services which have
been performed by psychiatrists, psychologists, social workers or other
licensed mental health professional. These invoices may include those which
have already been denied, or may not have ever been submitted. Regardless, you
are still entitled to receive reimbursement.
2. Be certain to include the following information with your claims. If it is not, ask the provider to include it — even by hand if necessary — and ask them to initial any such additions. Omitting any of these items will result in a denial based on incomplete information. Diagnostic evaluations, consultations, and psychological and neuropsychological testing should be covered as any other mental health service and should be submitted by you in the same way.
·
Diagnosis – ANY autism spectrum disorder, including PDD-NOS is
fine
***
Make sure the DSM-IV™ code is there and that the description of that code is to
(in parentheses next to the code), for accuracy: 299.0 (autistic disorder) or 299.80 (write
either Asperger’s, PDD-NOS or Rett’s Disorder in the parentheses, because all
three descriptive diagnoses, actually share the same DSM-IV™ 299.80 code) or
299.10 (Childhood Disintegrative Disorder)
·
An appropriate procedure code, called a “CPT code,” for the
service provided
***
CPT codes for RDI™, for example, would specifically use either a child code:
90812 (interactive psychotherapy, 45 min.) or an adult code: 90806 (individual
psychotherapy, 45 min.).
Note on RDI™ coverage: For those of you who are receiving RDI™ services from non-mental
health professionals, these new benefit changes only apply to mental health
providers performing RDI™ as part of the new mental health service coverage.
Providers of other specialties who provide RDI™ will still have to bill with
procedure codes for their specialty, and coverage will still be determined as
per your other plan benefits. For example, a speech therapist performing RDI™
could do so using a speech therapy code and get RDI™ therapy covered under a
speech procedure code for an ASD diagnosis.
·
Complete “descriptions” of each procedure code to specify the
service provided are needed: Below are
specific examples of descriptions (in italics) corresponding to each specific
CPT code for RDI™ services.
*** 90812
= “interactive psychotherapy, RDI™ therapy, 45 minutes” is a description for
RDI™ using a child procedure code.
*** 90806
= “individual psychotherapy, RDI™ therapy, 45 minutes” is a description for the
adult code (which can also be used for a child receiving the same services)
·
Write “Paid in-Full” on your invoices (assuming the invoice is
indeed paid).
·
Make sure that your provider’s name and mental health degree is on
the invoice
·
Make sure that your provider's tax ID# is on the invoice. This may
also be listed as a social security number, an FEIN# or an EIN#.
3. Because these claims are being submitted by you and not your provider, you must submit all of your invoices with a Subscriber Submitted Claim (SSC) form which you can download from Anthem’s website, (or call the customer service number on your card and ask them to FAX one to you).
***
This is the same form that you would have to use ordinarily to submit claims
for “out-of-network” providers, whom you have already paid.
***
If your provider is "in-network" and you have already paid those
claims, send a cover letter explaining such and also WRITE ON THE INVOICE “Paid
In-Full by Subscriber.”
As
such, it is important that you specify in your letter the following (and in the
following manner):
“Remit payment to:
<subscriber
name> (this is the subscriber member’s name, not the child’s name)
<subscriber
address>
<subscriber
city, state, zip>
…
and add, “DO NOT SEND PAYMENT TO THE PROVDER!”
Often,
therapists get reimbursed by insurers at a rate different (usually less) than
what they may have charged you in the past. That may leave the provider owing
you money for all the contractual “write-offs” they would have taken as an
Anthem provider (had Anthem not originally denied coverage). Deal with the
provider about this as each claim is paid, by
referencing the exact dollar amounts on each of your new Explanation of
Benefits (EOB).
*** All
in-network providers should NOW bill future claims to Anthem directly (it is
their legal contractual requirement). From now on they should EXPECT that
Anthem will pay them the insurance portion, according to their contractual fee
reductions. You should not be expected to pay the provider before you receive
the EOB. You will only owe the provider the portion denoted as “Amount You Owe
to the Provider” on each EOB. The EOB also shows you the amount of money Anthem
has paid your provider and the amount of money that Anthem has written off per
the provider’s contract. Do not pay the provider the amount written off if they
are in-network — only on out-of-network provider claims are you responsible for
paying that portion to the provider.
4. Fill out the SSC form completely. Sign and
date it. Finally, attach the claims that are referenced on that form.
*** The
directions tell you this, but notice that only one provider’s claims can be
listed on the same page. So, if you are submitting invoices from three
different providers, you will be filling out three forms (or more, if you have
numerous claims from one provider). Attach the invoices from that provider to
the back of that SSI form. The same provider might have listed three different
procedure codes for different services, but that is okay. Each forms is
“provider-specific,” not “procedure code-specific.”
5.
Do not send EOB denials to Anthem, either in lieu of finding your original paid
invoices or as additional information. It will impede your process of
collecting reimbursement for your claims.
6.
Every invoice/claim that EITHER you or your provider submit to your insurance,
should always be paid with a corresponding EOB mailed to you that shows the
action that was taken and why. If you do not receive an EOB, contact your
health plan by phone and request that they send you another copy. This should
be dealt with by Anthem over the phone as a routine request. Always monitor
your claims closely to make sure that all the dates of service have been paid.
If the EOB comes back denied with explanations such as “diagnosis code is not
valid for this procedure” or “claim should be submitted to the mental health
carrier,” or “not a covered benefit,” then something is amiss. In this
situation, contact Sarony Young at Family Voices of Colorado (303-973-5780).
7.
Before you put all of this in a big manila envelope, you should photocopy the
whole stack of paperwork in chronological order, and staple them together. Put
in a file for “Outstanding Anthem MH and SS therapy Claims.” Send important
documents such as these “Certified/Return Receipt Requested” through your local
post office. It will cost you a few dollars, but it will save you time and
money in the end. The insurance carrier is less likely to claim they lost or
misplaced your envelope this way. You can track your envelope through the U.S
mail and, by the signature; you will know who at Anthem received it.
*** If there are a lot of claims
for each provider, it is best if they go in separate envelopes and still sent
Certified/Return Receipt Requested. The claims will get divided up anyway and
will go to different claims specialists. Write the same info on the top of your
invoices/claims that you write on the cover letter to explain what the claims
are and who (you) gets the money from Anthem!
Relationship
Development Intervention and (RDI™) are trademarks of the Connections Center of
Houston, TX.