You should always bill your usual charge to BCBSLA regardless of the allowable charge, for the following reasons:

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1 Reimbursement Allowable Charges BCBSLA reimburses participating providers based on allowable charges. The allowable charge is the lesser of the submitted charge or the amount established by BCBSLA as the maximum amount allowed for provider services covered under the terms of the Subscriber Contract/Certificate. You should always bill your usual charge to BCBSLA regardless of the allowable charge, for the following reasons: It enables us to determine allowable charges for procedures and maintain allowances that are fair and equitable. Billing one standard charge to all insurance companies helps reduce the chance of billing errors. If more than one insurance company has liability for a claim, your standard charge eliminates confusion and helps to ensure proper payment. Allowable charges are provided to participating providers to help avoid refund situations. They are for informational purposes and not intended to establish fees. BCBSLA regularly audits our allowable charge schedule to ensure that the allowable charge amounts are accurate. From time to time we must adjust an allowable charge because it may have been incorrectly loaded into our system or the CPT code description has changed. Allowable charges are added periodically due to new CPT code or updates in code descriptions. If you need the allowable charge for a select code or group of codes, please call Network Administration at , option 3 or September 2002 IV - 1

2 SAMPLE WEEKLY PROVIDER PAYMENT REGISTER S PATIENT S NAME 3 10 DAYS ADMIT DT/ CLAIM TOTAL MD CONTRACT CPT4 PATIENT ABOVE ALLOWABLE AMOUNT STAT SCH PERFORMING C CONTRACT NO PAT ACCT DISCH DT NUMBER CHARGES CD BENEFITS REV LIABILITY AMOUNT PAID CD COB DRG PROVIDER PREVIOUS CREDIT BALANCE Doe John R /21/ S /21/00 ** CPT % ** CPT S ** CPT S ** CPT S ** CPT REJECT RD Doe Suzie Q /06/ , ,665.00CR 4,572.42CR 1, CR 1,665.00CR /17/00 1,65 CPY Doe Suzie Q /06/ , ,663.00AJ 3,526.00AJ 2, AJ 3,663.00AJ /17/00 1,65 CPY Smith Jane X /09/ , , , , S /09/ DED COI ** CPT % ** CPT % ** CPT % ** CPT % ** CPT S Smith John Q /20/ , ,072.17CR 4,697.27CR 5,072.17CR /31/00 1,05 CPY Smith John Q /20/ , ,331.00AJ 7,438.44AJ 2,331.00AJ /31/00 1,05 CPY TOTAL SCB: SCC: 21 BALANCE: $ (AMOUNT PAID) 23 CHECK NO: BLUE CROSS/BLUE SHIELD OF LOUISIANA PAID PROV: SAMPLE MEMBER PROVIDER 22 POST OFFICE BOX DATE: 10/23/ MAIN STREET BATON ROUGE, LA CHECK NO: ANYTOWN, LA / *Note: All charges are examples. September 2002 IV - 2

3 Provider Payment Register Following is a description of each item on the BCBSLA Weekly Provider Payment Register. A copy of the payment register appears on the preceding page. 1. Patient s Name - The last name and first five letters of the first name of the patient. 2. Contract No - The subscriber s Blue Cross and Blue Shield identification number. 3. Pat Acct. - The patient identification number assigned by the provider s office. This information will appear only if provided on the claim. 4. Admit Dt/Disch Dt - The beginning and ending date(s) of service for a claim. 5. Days - The number of visits that the line item charge represents. 6. Claim Number - The number assigned to the claim by BCBSLA for document identification purposes. NOTE: When making inquiries about a specific payment, always refer to this number. 7. Total Charges - The charge for each service and the total claim charges submitted to Blue Cross and Blue Shield. 8. Contract Benefits - The benefit amount payable by Blue Cross and Blue Shield according to the subscriber s contract. 9. CPT -4 Code - The code used to describe the services performed by the provider. 10. Patient Liability - The total amount owed by a patient for each claim including deductible, coinsurance, copayment, non-covered charges, etc. 11. Above Allowable Amount - The amount above the allowable charge. NOTE: This amount cannot be collected from the member. 12. Amount Paid - The amount paid by BCBSLA. 13. Stat CD A one- or two-position alpha code that describes the above allowable (if applicable) followed by a three-position alpha reject code that indicates why a claim was not paid (if applicable). 14. COB - An asterisk in this column denotes that Blue Cross and Blue Shield is the secondary carrier. 15. SCH DRG - Not applicable to providers. 16. Performing Provider - The name and ten-position provider number of the provider who performed the service. September 2002 IV - 3

4 17 Previous Credit Balance - This amount indicates the total of previous overpayments made to the provider. 18 Totals - The total of days, charges, contract benefits, patient liability, above allowable amount, and amount paid for all patients listed. 19. Total SCB - Not applicable to providers. 20. SCC - Not applicable to providers. 21. Balance - The amount adjusted by BCBSLA to recover any overpayments made to the provider. 22. Provider Name - Provider/Clinic name and address to which payment is made. 23. Paid Prov. - Provider s/clinic s BCBSLA provider number under which payment is made. 24 Date - Date the Provider Payment Register is generated by BCBSLA. 25. Check No. - The number assigned to the check mailed with the payment register. September 2002 IV - 4

5 Sample BCBSLA Explanation of Benefits 1 Grp # --- Name --- Address --- City, State, Zip--- EXPLANATION OF BENEFITS 2 THIS IS NOT A BILL Duplicate Copy Date Patient Contract# Group Patient Name Major Medical Network Accumulation Amount Satisfied YTD Deductible Coinsurance 6 Family 7 Provider or Type Services Date of Service 8 9 Amount Charged Not Covered Amount/Reason Deductible 12 Coinsurance Lifetime Benefits Paid for Other Carrier Benefits 13 Basic Benefits 14 Major Medical Benefits 15 Amount Credited 16 Total BENEFITS CREDITED TO PROVIDER COINSURANCE: THE PERCENTAGE OF THE COVERED CHARGES FOR WHICH YOU ARE RESPONSIBLE UNDER THIS CONTRACT. *REASON 19 EXPLANATION OR REASON NOTE: IF YOU HAVE FILED A CLAIM WITH BENEFITS ASSIGNED TO YOU, YOU WILL RECEIVE A SEPARATE EXPLANATION OF BENEFITS. September 2002 IV - 5

6 Explanation of Benefits (EOB) The Explanation of Benefits (EOB) is a notice sent to the subscriber after a claim has been processed by BCBSLA that explains the action taken on that claim. Following is a description of each item on the BCBSLA EOB. A copy of the EOB appears on the preceding page. 1. Subscriber s group number, name and address. 2. Date - The date the EOB was generated by BCBSLA. 3. Patient - Patient s first name. 4. Contract # - Subscriber s identification number. 5. Group - The number assigned to the subscriber s employer, association or organization. 6. The total year-to-date amount that the subscriber has paid toward his/her deductible and the total benefits paid by BCBSLA for this subscriber. 7. Provider or Type Service - The name of the provider who provided services. 8. Dates of Service - Date(s) the service(s) was/were rendered including from and to date(s). 9. Amount Charged - Total charge for each service rendered. 10. Not Covered Amount Reason - The amount of ineligible charges or services. A brief explanation of the reason a charge is not covered will appear in the Explanation of Reason #19. NOTE: The patient is not responsible for payment of any amount above the allowable charge. 11. Deductible - The amount, if any, applied to the subscriber s deductible. The patient is responsible for payment of this amount. 12. Coinsurance - The amount the subscriber is responsible to pay after the deductible has been met. 13. Other Carrier Benefits - The amount paid by another insurance carrier (Coordination of Benefits). 14. Basic Benefits - The total amount of benefits paid under the subscriber s basic health benefits contract. September 2002 IV - 6

7 15. Major Medical Benefits - The total amount of benefits paid under the major medical portion of the subscriber s contract. 16. Amount Credited - The total amount of benefits paid on behalf of a member. 17. Total - The totals of amount charged, not covered amount, deductible, coinsurance, other carrier payment, basic payment, major medical payment and total payment. 18. Benefits to Provider - The total amount of benefits paid. 19. Explanation of Reason - An explanation about a payment or ineligible service or charge. September 2002 IV - 7

8 Sample FEP EOB September 2002 IV - 8

9 Federal Employee Program (FEP) EOB The Federal Employee Program (FEP) is a health care benefits plan designed for personnel employed by the Federal Government. The FEP EOB is a notice sent to the FEP subscriber after a claim has been processed by BCBSLA that explains the action taken on that claim. Following is a description of each item on the FEP EOB. A copy of the FEP EOB appears on the preceding page. 1. Claim Number- The number assigned to the claim by Blue Cross and Blue Shield for document identification purposes. 2. Date the Claim was Received, Processed and Paid by BCBSLA 3. Patient s Name and Patient Account Number (Optional) 4. A Summary of Standard Option and/or Basic Option Benefits on This Claim See Page V Whether or Not the Benefit Check Has Been Enclosed Informs the subscriber if the payment has been sent directly to the provider or has been enclosed with their EOB. 6. Provider Name and Dates of Service Information for the Subscriber 7. Type of Service An abbreviated description of the types of services rendered by the provider. 8. Submitted Charges - The charges submitted by the provider for each service. 9. Negotiated Savings The amount above the allowable charge. 10. Non-covered Charges - A charge (for a non-covered service) for which there is no provision for either partial or total benefit/payment under the Subscriber Contract/Certificate. 11. Allowable Charges - The lesser of the submitted charge or the amount established by the PLAN, based on an analysis of provider charges, as the maximum amount allowed for physician services covered under the terms of the Subscriber Contract/Certificate. 12. Deductible - The specific amount of covered services, usually expressed in dollars, that must be incurred by a subscriber before BCBSLA is obligated to the subscriber to assume financial responsibility for all or part of the remaining covered services under a Subscriber Contract/Certificate. 13. Coinsurance/Co-pay The portion of covered services, usually expressed as a percentage (Coinsurance) or dollar amount (Co-Pay), for which the subscriber is financially responsible under a Subscriber Contract/Certificate. 14. Other Coverage The amount paid by another insurance carrier. 15. Explanation of Codes and Other Remarks A detailed explanation of any CPT codes used in the FEP EOB as well as other information pertinent to the subscriber. September 2002 IV - 9

10 Sample NASCO Provider Check Voucher September 2002 IV - 10

11 NASCO Provider Check Voucher Following is a description of each item on the NASCO (National Accounts Service Company) Provider Check Voucher. NASCO is a national accounts membership and claims processing system used by BCBSLA. A copy of the check voucher appears on the preceding page. 1. Sub. ID - The subscriber s identification number also referred to as contract number. 2. Patient s Name - Patient s last name and first three letters of his/her first name. 3. Patient Account - The account number assigned to the patient by the provider s office. This information will appear only if provided on the claim. 4. Prescription No. - Pharmacy claims only. 5. Claim No. - The number assigned to the claim by Blue Cross and Blue Shield for document purposes. 6. Service Dates From/To - The beginning and ending date(s) of service for a claim. 7. Procedure Code - The CPT procedure code(s) for the service(s) billed. 8. CVD/NCVD - The amount of charges that are covered or non-covered by a subscriber s policy. 9. Total Charges - The charge for each service submitted to Blue Cross and Blue Shield. 10. Allowed Amount - The lesser of the provider s charge or allowable charge on which benefits were based. 11. NCVD CHG - The amount not covered by a subscriber s health benefits contract. This amount is collectible from the subscriber. 12. Subscriber s Liability - The amount owed by a patient for each claim. 13. Co-Pay/Ded. - The total of copayment and/or deductible. This is the amount owed by a patient for each claim. 14. Approved To Pay Amount - The benefit amount payable by Blue Cross and Blue Shield according to the subscriber s contract. 15. Amount Paid - The amount paid by Blue Cross and Blue Shield. 16. A message that provides pertinent information about the claim. September 2002 IV - 11

12 17. Traditional Paid Claim Subtotals - The subtotals of charges, allowed amount, non-covered charges, subscriber liability, copayment/deductible, approved to pay amount and amount paid for all claims listed on the Provider Check Voucher. 18. Total - The total charges, allowed amount, non-covered charges, subscriber liability, copayment/deductible, approved to pay amount and amount paid for all claims listed on the Provider Check Voucher. 19. Provider Number - The number assigned to a provider/clinic for NASCO claims processing purposes. 20. Tax ID - The tax identification number under which claims payments are reported to the Internal Revenue Service for the physician/clinic to whom payment was made. 21. Payment Date - The date the Provider Check Voucher was generated. 22. For Related Inquiries Please Call or Write - The name, address and telephone number to which NASCO claims and inquiries should be directed. 23. Provider s/clinic s name and address September 2002 IV - 12

13 Sample NASCO EOB THIS IS NOT A BILL Explanation of Benefits Payments 1 STATEMENT DATE MON DAY YEAR CHECK REF NO: Contract#: 18 Group#: THIS STATEMENT REPORTS ON A CLAIM(S) WE RECENTLY PROCESSED FOR YOU AND/OR YOUR DEPENDENTS. IF YOU HAVE ANY QUESTIONS PLEASE CALL OR WRITE: BLUE CROSS BLUE SHIELD OF LOUISIANA NASCO DEDICATED UNIT P.O. BOX BATON ROUGE, LA Patient: Provider: Claim: DATES OF SERVICES 11/27/ DESCRIPTION OF SERVICES AMOUNT CHARGED 4,35 ALLOWED AMOUNT 2, OTHER INSURANCE $ 9 YOUR RESPONSIBILITY DEDUCTIBLE COPAY COINSURANCE OTHER AMOUNTS NOT COVERED , AMOUNT PAID 2, RSN CODE 16 R 11/27/ , , R 11/27/ Explanations: R- Service Is Not A Covered Benefit. (E232) 20 PLEASE KEEP YOUR RECORDS. THIS IS A DUPLICATE. BLUE CROSS BLUE SHEILD OF LOUISIANA NASCO DEDICATED UNIT P.O. BOX BATON ROUGE, LA /670 T Subscriber Name Subscriber Address Anytown, LA September 2002 IV - 13

14 NASCO EOB NASCO is a national accounts membership and claims processing system used by BCBSLA. The NASCO EOB is a notice sent to the subscriber after a claim has been processed by BCBSLA that explains the action taken on that claim. 1. Statement Due - Date the EOB was generated. 2. Patient Name - The last and first name of the patient. 3. Provider s Name - The name of the provider who performed the service. 4. Claim Number - The number assigned to the claim by Blue Cross and Blue Shield for document identification purposes. 5. Dates of Service - The beginning and ending date(s) of service for a claim. 6. Description of Services - A written description of the types of services rendered. 7. Amount Charged - The amount charged for each service. 8. Allowed Amount - The benefit amount payable by Blue Cross and Blue Shield. 9. Other Insurance - The amount paid by another insurance carrier. 10. Your Responsibility - The total amount owed by a patient. The deductible, coinsurance and other subscriber liability amounts not covered are itemized. 11. YTD Deductible Amount - The year-to-date amount that has been applied to a subscriber s deductible. 12. YTD Co-pay - The year-to-date aggregate co-pay paid by the subscriber. 13 YTD Coinsurance - The year-to-date aggregate coinsurance paid by the subscriber. 14. Other Amounts Not Covered The difference between the amount charged (Item 7) and the allowed amount (Item 8). This is the amount the participating provider has agreed not to collect from the member. 15. Amount Paid - The amount paid by Blue Cross and Blue Shield. 16. RSN Code - A code that provides pertinent information about a claim. A detailed explanation of the RSN code appears in Item Check Reference Number The number of the check submitted for charges. 18. Contract Number - The subscriber s identification number. 19. Group Number - The number assigned to the subscriber s employer, association or organization. 20. Explanation of Column 16 - A detailed explanation of the code contained in Column Subscriber Name/Address September 2002 IV - 14