Claims submission form for Anthem Medicaid Prepay Audit Claims submission for Anthem Medicaid Prepayment Audit Use this form to submit claims for the Anthem Medicaid Prepay Audit. This form must be complete for claims submission to proceed. The special Investigations Unit (SIU) aims to detect and deter fraud, waste and abuse, and verify whether services billed, pursuant to Anthem Blue Cross and Blue Shield Medicaid (BCBSKY) policies and guidelines, the American Medical Association (AMA) Current Procedural Terminology (CPT) and / or Healthcare Common Procedural Coding System (HCPCS) and other applicable industry standards are billed accurately and supported through documentation. We will not pay miscoded services or excessive units based on these generally accepted coding practices. This letter is to inform you that we will place your practice on prepayment review for any submitted claims with date of service on or after Effective October 14, 2024. . Each claim you submit that seeks reimbursement for the code 90837 must include medical records that support the billing of the specific code.Provider Name(Required) First Last Provider Email(Required) Client Name(Required) First Last A CASII OR LOCUS OR ESCII IS REQUIRED FOR THIS AUDIT TO PROVIDE PROOF OF MEDICAL NECESSITY. Is client 18 or older?(Required) Yes No Documentation ReviewBiopsychosocial within last 12 months(Required) Yes No Due date for next Biopsychosocial update(Required) Is Client receiving Intensive Services?(Required) Yes No Definition of Intensive Services: Intensive Services include any  psychotherapy session that extends beyond 1 hour or more than 1 session per week.  A 75 plus minute session applies.  Two or more psychotherapy sessions of any length per week apply.  Two or more psychotherapy services provided per week by different therapists also applies.  (This does not include psychiatry.) Any provider use of the add on code H0004 is considered an intensive service. And any use of Targeted Case Management Services and/or Community Support Services are considered an intensive service. Is an SED or SMI form present in the chart.(Required) Yes No, the documentation will be completed and submitted with this form No, client does not qualify for SED or SMI determination Provide a separate SED/SMI form besides the references to this determination in other assessment forms such as the biopsychosocial or level of care assessment. We want to be sure that the investigators who are auditing your chart see this form.Clients receiving intensive services must qualify for SED or SMI. Without it intensive services are not eligible for reimbursement for servicesTreatment Plan within the last 3 months?(Required) Yes No Clients receiving intensive services must have an updated plan every 3 months.Treatment Plan with in the last 6 months?(Required) Yes No Treatment plans for Medicaid clients must be updated every 6 months at a minimum. Those receiving intensive services should be reviewed every 3 months.Date Treatment Plan Completed(Required) MM slash DD slash YYYY Level of Care Assessment in the last 3 months(Required) Yes No For clients receiving intensive services, do a level of care assessment every three months. Does this assessment support the use of intensive services? Transformations is limiting intensive services to clients with a level three or higher. Level 2 clients do not qualify.Level of Care Assessment in the last 6 months(Required) Yes No All Medicaid clients need a level of care assessment to document that there is a need for psychotherapy services. Date Level of Care Assessment Completed(Required) MM slash DD slash YYYY Level of Care Score(Required) 0-No services are medically necessary 1-Brief therapy (6 sessions or less) 2- Traditional Outpatient Therapy 1 x per week or less and up to 60 minutes per session 3- Intensive Home and Community Based Services 4 or more - group home, residential or hospitalization Are the interventions on the treatment pan consistent with the Level of Care rating identified in the CASII/LOCUS/ESCII ?(Required) Yes No Make sure your documentation is consistent on all forms. If your LOC and treatment plan say level 2, are the interventions on the treatment plan listed as 1 x week or less. Never copy old treatment plans without updating the assessment scores, level of care rating and the frequency and intensity of psychotherapy sessions. Are the frequency and intensity of services for which you are submitting claims consistent with the frequency and intensity recommended by the level of care assessment tool(CASII/LOCUS/ESCII?(Required) Yes No Check the frequency of services you provided against your LOC and treatment plan. comments Which assessment tools were used to support the diagnosis and problems and show medical necessity for treatment?(Required) PHQ-9 GAD-7 AUDIT ADHD No assessment tools were found in the chart Other? Assessment tools support your diagnosis and frequency and intensity of services. Transformations provides web-based tools in the website library under Forms and Links and Assessment and Diagnosis Tools. (PHQ-9 and GAD-7) These completed tools can be uploaded to the attachment page in MCP. Other tool Assessment tools should be documented in the biopsychosocial, the treatment plan, and on the progress note to help show measurable progress. The progress notes meet the following requirements. You may add a note correction addendum if you find missing data.(Required) Problems/goals on the note are copied from the latest treatment plan Measurable outcomes should be measured and updated each session (this section changes at each session) Intervention include a theory of therapy or a definition of psychotherapy Interventions include what the therapist did that day during that specific session. This is unique to the session and changes on every note. Plan includes planned frequency of sessions and date for treatment plan update Response section should describe client's response to your interventions Length of note should reflect the length of the session with at least one paragraph per hour spent in the session Other Watch for what Medicaid calls Cloning of session notes. This happens when we copy and paste the same thing in every note. Cloning is evident when he/she references don't match the gender of the client.Other Problems with my progress notes: The Progress Notes need work to comply with the following requirements: You may add a note correction addendum if you find missing data.(Required) Problems/goals on the note are copied from the latest treatment plan Measurable outcomes should be measured and updated each session (this section changes at each session) Intervention include a theory of therapy or a definition of psychotherapy Interventions include what the therapist did that day during that specific session. This is unique to the session and changes on every note. Plan includes planned frequency of sessions and date for treatment plan update Response section should describe client's response to your interventions Length of note should reflect the length of the session with at least one paragraph per hour spent in the session Other Watch for what Medicaid calls Cloning of session notes. Do your notes all read the same? Or do they show individualized care with progress or change over time?Comments The chart contains the following documents. Review the attachments in the MCP chart and mark here the CURRENT and UPDATED forms that are present in the chart.(Required) Permission to Treat Emergency Release Form Authorization to Share Information with Primary Care Physician (PCP) Treatment Plan Signature Page Treatment Plan Level of Care Assessment (required on all clients for the purposes of the Anthem audit) SED/SMI form Biopsychosocial Authorization to share Information with TCM Authorization to share information with Psychiatrist Review the required forms in the MCP attachment section. Are they CURRENTand UPDATED? Obtain any missing client forms. before requesting submitting this request for claims submission. Don't mark forms that are outdated or need replacing.Missing Documents: The chart is missing the following updated enrollment forms(Required) Permission to Treat Emergency Release Form Authorization to Share Information with Primary Care Physician (PCP) Treatment Plan Signature Page Treatment Plan Level of Care Assessment (required on all clients for the purposes of the Anthem audit) SED/SMI form Biopsychosocial Authorization to share Information with TCM Authorization to share information with Psychiatrist I reviewed the forms in the MCP attachment, and they are all present and updated. Review the required forms in the MCP attachment section. Obtain any missing client forms. before requesting submitting this request for claims submission.Credentials of rendering provider are evident on all documents?(Required) Yes No I added my credentials to my name in a note addendum. I reviewed the LOC and SED/SMI to verify that they include my credentials. When you print your note look at the top of the page for your digital signature. Did you remember to write your credentials after your last name? if you forgot, add an addendum that merely states your name and credentials. Failure to add your credentials will result in a denial of payment.Which documents are missing the credentials?(Required) CommentsInformed consent(Required)I understand the client chart and these documents are being reviewed by the Blue Cross and Blue Shield Special Investigation Unit for evidence of fraud and abuse. I have reviewed the client chart for accuracy and declare that the chart documentation and claims are an accurate description of the services I have provided to this client. I have read and agree to the submission of claims for this client.Signature(Required)Client meets qualifications for the following level of care: Intensive Home and Community Based Services (level 3 or higher)) One hour or less of psychotherapy per week but no intensive services (level 2) Brief therapy-6 sessions or less (level1) Client does not qualify for services (level. 0) HiddenAuditor Email Attach Documents as PDF FilesAttach documents that will be submitted with your claim. You may add up to 2 session notes to this form. Make sure the dates of service are covered by the treatment plan due date. Do not submit this form without the required documents. Forms must be submitted as PDF file. Tip: When you download documents from MCP, use the Print Note button. Then save to a PDF rather than your printer. 1. Progress Note(Required)Max. file size: 32 MB.One Note Only. do not send multiple notes or multiple dates of service. 1. Date of attached session note MM slash DD slash YYYY 2. Progress NoteMax. file size: 32 MB.One Note Only. do not send multiple notes or multiple dates of service2. Date of attached session note MM slash DD slash YYYY Biopsychosocial(Required)Max. file size: 32 MB.Add the date completed on the file nameTreatment Plan(Required)Max. file size: 32 MB.Add the date completed on the file nameLevel of Care Assessment(Required)Max. file size: 32 MB.Add the date completed on the file nameSED/SMI formMax. file size: 32 MB.Assessment ToolMax. file size: 32 MB.Assessment ToolMax. file size: 32 MB.Treatment Plan Signature Page(Required)Max. file size: 32 MB.Add the date completed on the file nameOther supporting documentationMax. file size: 32 MB.Other supporting documentationMax. file size: 32 MB.Other supporting documentationMax. file size: 32 MB.WARNING: Attachments are not saved when using the Save and Sign Button.EmailThis field is for validation purposes and should be left unchanged.
