I have a high deductible plan through Anthem and was fortunately enough to max out that deductible via surgery. Thats all covered just fine. However, I had some unrelated routine medications to fill. One I had filled without insurance coverage which is typically fine since I usually use minimal healthcare resources. I try submitting it online - I don't find a form for pharmacy benefits so I submit for medical, fudging a couple of fields in order to get it to submit. Well, I get a letter saying my claim needs a ICD10 diagnosis code and a leagacy (sp?) number. I call anthem who explains my pharmacy benefit is handled by CarelonRx...which I'm preeeeety sure is a subsidy of anthem. For nearly an hour I have both companies on the phone while they try to figure out how I'm supposed to submit my claim. It seems I'm unable to submit it through either company properly. The CarelonRx employee offers to mail me some forms - which I accept but this is still obviously a broken system. My call is dropped as I'm asking for a callback number (of course) - I do get a call back from anthem and the rep offers to see if they can email me the forms. Of course they can't. They do make the useful suggestion of trying Anthem's app - I can see my pharmacy claims but I can't submit new ones.

At this point I wish I had a giant health insurance voodoo doll that I could kick in the nuts. They literally can't do their @#$%& job and it becomes my job to sort it out.

---

"I call anthem who explains my pharmacy benefit is handled by CarelonRx...which I'm preeeeety sure is a subsidy of anthem. "

The muthuh of all muthuhs. Elevance Health owns a zillion other companies that do their dirty work for them.
One hand doesn't wash the other, it is the other.
I have the same issues at times with EBCBS, also Elevance.

They suck monkey wiener.

Get the voodoo doll.

---

!#$@@$#!

Quod suus via crustulum saxum

Ask them if they can cancel the claim and resubmit it from their end as a simple refill on medication.

See if you can find a previous claim online, or an explanation of benefits doc showing those meds, and give them that for reference so they can crib off of it.

---

How long has it been since the date of service (date you picked up the rx)? Depending on how long it’s been and which pharmacy, your pharmacy may be able to reverse and refill the claim. Most pharmacies can do it for a few weeks after the service date. Walgreens I know is limited to a week based on their own systems.

Yes anthem (elevance) is the parent of carelon, but the benefits are separately managed. This is pretty common , depending on how you get your benefits and what the contracts with your plan sponsor dictate. Prescriptions don’t run through medical-only benefits, so anthem appropriately redirected you. Carelon may make their direct claims form available online, if not as you said they are mailing it to you. As an alternative, you could use a universal claim for (your pharmacy may be able to share - I won’t link any here because Medicare has different requirements than commercial and I have no idea what version you would need).

It’s always better to run through insurance at point of sale compared to post- reimbursement. You may well find you don’t get your full expected reimbursement, depending on your plan design. It’s super common to refund based on the contracted reimbursement rate with your pharmacy, which tends to be lesser than cash price. That means you pay more via the cash now, reimburse later method than if you just ran through insurance first.

Quote
Tiangou
Ask them if they can cancel the claim and resubmit it from their end as a simple refill on medication.

See if you can find a previous claim online, or an explanation of benefits doc showing those meds, and give them that for reference so they can crib off of it.

Absolutely won’t happen. A previous claim has no standing toward a new claim. There are so many variables that may change that the patient will never see that absolutely make a difference in how the claim processes. Like, Something as seemingly simple as the quantity in the stock bottle filled from - you as patient wouldn’t know there was a change, but the insurance needs this and cares about it.

Quote
TL

Quote
Tiangou
See if you can find a previous claim online, or an explanation of benefits doc showing those meds, and give them that for reference so they can crib off of it.

Absolutely won’t happen. A previous claim has no standing toward a new claim...

It's just a template for their reference because they're probably too dull to know how to enter it from scratch.

Assuming that this is a refill ("routine medications"), it should be almost exactly the same as the last one. If it's a new prescription, god speed.

---

Edited 1 time(s). Last edit at 01/03/2023 07:31PM by Tiangou.

Quote
Tiangou

It's just a template for their reference because they're probably too dull to know how to enter it from scratch.

Assuming that this is a refill ("routine medications"), it should be almost exactly the same as the last one. If it's a new prescription, god speed.

Having been on the other side (I work for a competitor to the mentioned orgs), it’s absolutely not a matter of needing a template, or of being “too dull” to process the claim. It’s a matter of getting required info to comply with each plan sponsor’s requirements, and industry/state/federal requirements. The template (form) is there to help the patient ensure they are submitting the right info the first time. Carelon can process anything sent to it, but if it isn’t the needed or right info, it’s just going to result in a reject (meaning delay in getting $).

Nothing is “just a refill” in the pharmacy world. you may not be aware, but any of the following can and I have seen change, affecting if/how the claim pays: NDC ( brand or generic manufacturer, quantity of stock bottle); DAW code (1 or 2 get you the same product but can affect the payment), prescriber NPI/DEA (NPI required for Medicare), etc. you still get your Fukitol meds, but the paperwork changes to accurately reflect what occurred. Again, the typical patient would have no clue or care to know about what goes on behind the scenes. All of which is handled for you by your friendly pharmacist when you hand over your insurance card.

I defer to your expertise.

---

Yea...for future reference you never want to be the one entering an RX claim. The entire system is setup for pharmacy claims, not individual claims. Always have the pharmacy run it through the insurance.

---

C(-)ris
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Lesson learned I guess.

Although I'll point out that you can sometimes pay less by buying without insurance. And I'm in the rare care where I can pick my price and get it covered.

---

Quote
mattkime
Lesson learned I guess.

Although I'll point out that you can sometimes pay less by buying without insurance. And I'm in the rare care where I can pick my price and get it covered.

Any decent pharmacy will run it both ways to see which is cheaper.

---

C(-)ris
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Quote
C(-)ris

Quote
mattkime
Lesson learned I guess.

Although I'll point out that you can sometimes pay less by buying without insurance. And I'm in the rare care where I can pick my price and get it covered.

Any decent pharmacy will run it both ways to see which is cheaper.

i've noticed they're getting better at that but I guess I've been slow to trust them.

...you know, its still interesting that the insurance company reps were convinced that there should be some sort of method of online submission.

---

Would this claim form work? First hit in a google search.

[www.wellpoint.com]

Or this if you have an online account setup with them?

[www.carelonrx.com]

Quote

Where can I download forms or a new member ID card?

Once you log in to your CarelonRx member account, select “Access Your ID Card” from the menu and choose your preferred delivery method for your replacement ID card. To download commonly used forms, select “Support” from the top navigation and navigate to “Forms.” There you will find a list of commonly used forms. You can call the Member Services number on the back of your ID card to speak with a representative, 24/7. Alternatively, your pharmacist can call the CarelonRx Pharmacy Help Desk.

Quote
TL

Quote
Tiangou
Ask them if they can cancel the claim and resubmit it from their end as a simple refill on medication.

See if you can find a previous claim online, or an explanation of benefits doc showing those meds, and give them that for reference so they can crib off of it.

Absolutely won’t happen. A previous claim has no standing toward a new claim. There are so many variables that may change that the patient will never see that absolutely make a difference in how the claim processes. Like, Something as seemingly simple as the quantity in the stock bottle filled from - you as patient wouldn’t know there was a change, but the insurance needs this and cares about it.

Just to be clear - I give zero @#$%& about all that as I feel all consumers should. The insurance industry creates fragile processes and has trouble implementing them with clarity.