Gap in Health Insurance

My wife is the owner and sole practitioner of a Mental and Behavioral Health therapy practice. The business was established earlier this year and the bulk of the current clients are part of Anthem commerical insurance plans.

Prior to 8/15/22, all claims for the same services for these same members were being approved and paid within a few days of submission. However, since 8/15, all commercial claims have denied with the primary reason cited being that the provider is not covered. However, both our local rep and the live agents we have called have unanimously verified that we are in network and that members are still eligible.

We have spent roughly 50 hours of follow-up regarding the issue at this point and have called the claims, provider experience, EDI, and general provider support line. We have also been sending daily emails to the local provider representative in our territory. The best response we have received so far is that they can submit the claims one by one for reprocessing and that there is likely an error within our profile information in Anthem’s new claims system. Anytime that we have been escalated to speak with a supervisor, we have received no additional context around the root cause of this issue.

Since we are a new business with such a heavy % of our payer mix bring comprised of Anthem commerical, this issue is threatening the financial viability of our business. We understand that the issue has only been occurring for six weeks, but with claim reprocessing taking 30-45 days just to get any feedback, we are becoming very worried.

Does anyone have any suggestions of what else we may try to get someone at Anthem to look into the root cause of this issue?