Tips for escalating an Anthem claim to TCCN:
TCCN can escalate Anthem claims practices feel were denied or underpaid in error.
All claims must be disputed/appealed and a reference number obtained before escalating to TCCN.
- Obtain reference number for all claims from Availity or by calling Customer/Provider Services.
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Anthem will not accept an escalation from TCCN without a reference number.
TCCN can submit claim processing errors related to provider issues only.
- Examples include out of network claims, denials for incorrect addresses/data, and fee schedules inconsistencies.
For out of network denials, confirm the front office staff is verifying the PCP on the date of service. If a member sees a provider within the same practice (same Tax ID), but different than their listed PCP, Anthem should cover the claim because they are under the same practice (Tax ID).
- Confirm the patient’s PCP is documented as a provider in your practice on the date of service. You may be asked to provide proof.
- If the patient’s listed PCP is not in the practice, the member should call Customer Service, change their PCP, and initiate the claim to be reviewed. The member has 90 days to initiate the correction.
- TCCN cannot have the PCP updated for a claim already processed. This must be completed by contacting Customer Service.
- The practice can also appeal by providing the reference number or proof of provider portal documentation showing the PCP was correct on the date of service.
- Anthem will not reprocess claims with a PCP outside of your practice when asked by TCCN.
Member benefit disputes cannot be resolved through TCCN.
- Practices must resolve benefit issues with the members benefit plan or the patient’s employer group, if needed.
Use the enclosed claim template when submitting an escalated claim to your TCCN Rep. The following information is required:
- rendering provider and service location
- member information, including practice's patient account number
- reference number, detailed summary of concern
Anthem Practice Claims Template
If a refund is required, a refund notification is sent to the provider on their Remittance Advice.
- Out of state plans require a full refund of the initial claim payment to make claim adjustments and pay corrected rates. This can take up to 90 days.
- For Georgia plans, Anthem send an “add pay” for any additional payment and does not require full refund. This can take 7-10 business days.
For additional resources, please review the Anthem Georgia Facility and Professional Provider Manual, page 54-57 PM_GA_0124.pdf (anthem.com).
There are several options to file a Claim Payment Dispute:
- Online through Availity
- Call the number on the back of the Member ID Card
- Mail all required documentation to:
Anthem Claim Payment Dispute
P.O. Box 105449
Atlanta, GA 30328-5449
Remember to check the KHF Intranet for fee schedules updated in 2024.
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