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PHP and Anthem Requirements

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We recently were informed by anthem that they expect PHP services to be 6 hours a day 5 days a week and they are using that standard to deny entire weeks worth of claims when the patient only missed one day. Has anyone had experience with this?

So they are saying that because the patient missed the 1 day they won't pay any of the other days?  I don't have experience with this specifically, but I would make sure you are clear on the exact reason for the denial.  If that were the denial why would they not pay all of the dates leading up to the missed day?  Sometimes the denial is incorrect so that is why I'm asking.

If that is the denial, then I would appeal citing the reason the patient missed the 1 day.  For example, if the patient had a stomach virus and was vomiting, etc.  Or if the patient had a funeral to attend.  If there is a valid reason for the patient missing then I would appeal based on that.

Another thing is you could ask for the patient's benefits.  Meaning, does it state in their policy that PHP is only covered IF the patient has consecutive visits and is not covered if a date is missed.

We have gotten more information on this- apparently last year in August/September Anthem released a new policy # C-19002 siting that PHP services require 6 hours a day and 5 days per week to qualify. We are seeing it with more and more patients at this time.

At least you know the requirements now.  But if the patient only missed 1 day they should have qualified, right?

According to my last conversation with Anthem- they expect to see 5 in a week and if less it will likely deny and the only way to try and get around that is to provide a narrative on any missed days or hours. We are currently experimenting with their request to submit the days 5 at a time on a single claim form using 5 separate lines at 1 unit a pop. At this juncture I have multiple patients where most of their stay was denied due to them missing a day a week for illness or noncooperation.


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