bcbs pmap

amybenson 4 years ago in Payments/ERA Modules updated by Shauna Dall 4 years ago 8

Is anyone else still receiving a short pay on claims from BCBS PMAP? I bill for H2012 UA HK and the DHS rate for 1 hour is $65.26. BCBS PMAP prior to January 2019 paid $67.21 a hour. Now I am receiving $32.39/$32.38 a hour across the board. I have asked for "Project" to be opened to capture my incorrectly paid claims and have not been successful with customer service at Amerigroup. Our Provider Rep doesn't respond back to any emails or phone calls. Any advice or what is everyone else doing?

We cant even find out who our rep is as no one will tell us/give us any answers . We are still fighting with the April auths for the H2014 and now travel time. They are supposed to follow DHS standards and they are definitely doing that

T, were you on the conference call?  

Current update from the Aspire call - 

  • BP is briefly relaxing requirements for Timely Filing for Jan-June claims.  There is a project opened up for timely filing denials and they are working on adjusting.
  • BP is updating the platform for prior authorizations.  If a code is on the 'needing authorization' list it does require prior auths.  If not, it is a part of the adjustment project.  Thousands of claims are in processing status to be sent back for payment/adjustment for the prior auth rejection.  They expect this project to be completed by end of July, it went into effect last week for those that are already seeing claims reprocessing.  They are adjusting in bundles, by code, so as to not miss anything.  Additionally, the codes requiring 'notification' will have that requirement removed shortly.  There is a current list of codes requiring auths on the website, I think someone on a previous BP issue thread shared that link.  If any codes change to begin or end requirement of authorization, BP will provide a minimum of 45 day notice.
  • If you have called on the authorization or timely filing denials and were told something different (use one auth form or another, does/does not need auth, etc.) you can request an appeal and please provide that data.  If you have proof of that and it falls under the actual legitimate auth requirement your claim will be overturned.
  • If you have many/bulk appeals, please contact the call center and request direction on how to process.  They do have a process for bulk appeal requests.  (*I know for OPTUM issues we create an excel file with the pertinent data and send the file to our rep to review/forward.  This process works well for us).
  • It is confirmed that the H0046 code will be in the adjustment recoveries for all programs except EIDBI.
  • Additionally, there was an issue on the platform on June 3rd that briefly halted the 'pass thru' of claims through the edit system.  Your claim may be missed or mis-processed so that is something to watch for.  I know we have decided that anything unpaid at this time with sent date of June 3rd, will be resent to BP this week.
  • One last item - the dupe edit logic for codes with multiple modifiers is being opened as a project.  BP identified that they know the logic is too tight.  i.e. when you get denials for same service, same date CO18's when H2014 UA Ind Skills and H2014 UA HQ Group Skills are provided on the same date.  I think this may also be the same/similar for CD coding outpt services.

Hope this helps!  :) 



I missed getting on the conference call yesterday. THANK YOU so much for posting the above information!


I have a email for the Research@anthem.com that I will contact and see how to proceed. See if I can send a spreadsheet for appeals since the Provider Rep doesn't respond back to any inquiries.

and this email is not good...:( back to calling amerigroup, wish bcbs pmap plans could just be processed the way they were in 2018!

Anthem seems to be the worst one to deal with.  Amy, can you email me directly?  I may have a person you could contact, but I don't want to blast that and lose the only person we have gotten ahold of in years.