Navigating the Blues Training Guide

Transcription

1 Navigating the Blues Training Guide Billing Orientation Welcome to Navigating the Blues! Today s seminar will provide valuable information on our Health Plan, our billing guidelines, remittances, website tools and much more. We recommend that you keep this guide at your desk as it contains information that can help you navigate the blues every day! 2018 B-4605

2 Billing Orientation Table of Contents Course A Billing Overview & Highlights...2 A.1 Claim Submission Overview... 3 A.2 Before You Bill... 7 A.3 Course A Review... 9 Course B Paper Claims B.1 Optical Character Recognition B.2 CMS-1500 Claims B.3 UB-04 Claim Form B.4 Helpful Hints for Coding & Billing B.5 Course B Review Course C Electronic Claims C.1 Electronic Claim Clearinghouse C.2 Electronic Claim Processing C.3 Common Payer System Rejections for Electronic Claims C.4 Course C Review Course D Provider Remittances D.1 Excellus BCBS Remittance Highlights D.2 Remittances D.3 Course D Review Course E Troubleshooting E.1 Requesting Claims Adjustments E.2 Examples of Claim Adjustments Overpayments or Credit Balances: Denials Showing Additional Information Needed: E.3 BlueCard Claim Adjustments E.4 Clinical Editing Denials E.5 Involving the Member E.6 Maximizing Receivables E.7 Course E Review Course F Website Tools F.1 Website F.2 Course F Review

3 Course A Billing Overview & Highlights Claim Submission Overview...A.1 Before You Bill...A.2 Course A Review...A

4 A.1 Claim Submission Overview As a participating provider with Excellus BlueCross BlueShield, you need to submit all claims, including those for local subscribers, out-of-area subscribers and primary and secondary claims, to your local BlueCross BlueShield Plan. Most participating provider agreements contain a time limit within which claims will be accepted, so providers should submit all claims as soon as possible after rendering service. Claims submitted after that time limit may deny for late filing. Submitting Claims to Excellus BCBS Excellus BCBS accepts both paper and electronic claims. As mentioned above, submit all claims, including those for local subscribers, out-of-area subscribers, and primary and secondary claims, to your local BCBS plan. For workers compensation and no fault claims, please use the No Fault, Workers Compensation and Medicare Exhausted Benefits form available via our website, ExcellusBCBS.com/ProviderContactUs > Print Forms. If you are located in a county that borders multiple Blues plans, submit claims directly to the member s Home Plan, when you have a participating provider agreement with that BCBS plan. Electronic Claims New York State Public Health Law (Section 2807-e) mandates that claims must be submitted electronically unless you have filed for a waiver with the New York State Department of Insurance. This exemption affects providers with a low volume of claims. Electronic claim submission is the fastest, most efficient way to submit claims for reimbursement. Electronic claim submission has many advantages including: Speed: Efficiency: Precision: Response Reports: Claim turnaround time reduced through bypassing the paper process Access to claim status is typically within 48 hours from claim submission Electronic claim adjudication reduces manual errors, resulting in more accurate posting Interchange Acknowledgement (TA1) - reports errors only. Identifies problems in the interchange control structure, verifies the envelope structure and identifies duplicate interchanges. Generated immediately if file rejects. It is not generated if the file does not have an interchange control error. Clearinghouse Acknowledgement Report (999) - indicates whether the transmission was successful. Clearinghouse Response Report (277CA) - validates claims and lists both accepted and rejected claims. Payor Response Report (NYSCOP) - shows rejected claims available hours after submission

5 Excellus BCBS works closely with electronic billing software vendors to accommodate the testing of their programs. Once testing has shown that the vendor has met the necessary specification requirements, electronic billing can begin through the vendor s software. To bill electronic claims directly, you need: A personal computer Practice management software from a certified ANSI 837 vendor; or A contractual agreement with an electronic billing service or clearinghouse to submit claims on your behalf To connect to the clearinghouse, you need one of the following: SFTP client (80 byte, either wrapped or not) Rapid network connection To begin submitting claims electronically, contact our EDI Solutions department: edi.solutions@excellus.com NOTE: You cannot connect via dial-up, it must be a SFTP connection. Paper Claims Paper claims must be submitted on the CMS-1500 claim form for professional providers and UB-04 claim form for institutional providers. A combination of optical character recognition and human data entry is used to scan all paper claims. Claims submitted with missing or invalid information will be mailed back to you. Paper claim examples and instructions on how to complete these forms are included in this training guide. Remember: o o Professional providers must use the CMS-1500 claim form created by NUCC for all claim submissions Institutional providers must use the UB-04 claim form created by NUBC for all claim submissions Observe the following guidelines to ensure timely processing: Entries should be clearly typed and dark enough to be legible. Claims should be submitted on the original red and white claim form to ensure best possible scanning. Forms should be properly aligned prior to printing so information prints in the appropriate field. There should be no highlighting or handwriting on any section of the form. Do not use red ink as it will not get scanned/captured Complete all required fields as indicated. Fields of vital importance include: Subscriber ID, including prefix if applicable Patient name, gender, DOB and relationship to subscriber Dates of service Charges for services NPI and Tax ID Number, primary insurance information, including EOB, for secondary claims

6 AMA HCPCS/CPT codes and CMS valid diagnosis codes Number of service units If assistance is needed with the guidelines for billing claims, contact your Provider Relations representative. Mailing Address for Paper Claims: Claims Department PO Box Eagan, MN Claim Filing Limits Participating providers should submit all claims as soon as possible after rendering service (or after the paid date of a primary payer s explanation of benefits or EOB). Professional providers: 120-day claim filing limit applies Hospitals: Refer to hospital contract for claim filing limit. The filing limit for Coordination of Benefit (information on COB provided on following page) claims begins on the date of payment from the primary payer. Claims submitted after the time limits will be denied for late filing. Submitting Secondary Claims Our subscriber contracts allow us to coordinate payments with other payers when a member is covered by more than one health insurance policy. This is called Coordination of Benefits (COB). COB claims can be submitted electronically. To balance secondary electronic claims, the following information is required from the primary carrier s EOB: Allowed amount Deductible, coinsurance and/or copay applied Contractual adjustments/reduction of charges and description of associated reason codes Payment amount Patient responsibility Other carrier paid/process date For secondary paper claims, we require a copy of the primary carrier s EOB with the submission of the secondary claim Please attach the primary EOB on a separate sheet of paper

7 Medicare Crossover Claims Do not send claims to us if the primary payer is Medicare. Medicare will cross the claim over to us directly. For out-of-area BCBS plans, Medicare will crossover claims directly to the member s BCBS plan. If the EOMB from Medicare indicates that the claim has been forwarded for processing, please suppress the secondary billing of these claims. If you do not receive payment from us for a secondary Medicare claim, please wait a minimum of 30 days from the Medicare payment date before submitting the claim to us

8 A.2 Before You Bill Before You Bill Here are some helpful hints to follow before billing a claim: Verify the patient s insurance information at the time of the visit including eligibility, benefits and preauthorization requirements for the services that will be performed. Verify that you are a participating provider with the patient s insurance or the specific product for that patient. If the patient has managed care coverage and you are providing primary care services, verify that you are the primary care physician (PCP) listed on the patient s member card and with the insurance company. If you are not listed as the PCP on the member card, the member must contact us to update his/her PCP information or a referral must be obtained. If neither of these situations occurs, services will not be covered and the patient will be held harmless (not be responsible for payment). If the patient has a managed care contract and you are a specialist, verify if a referral from the PCP is necessary and on file (if applicable). If a referral is necessary and is not on file, the service will not be covered and the patient will be held harmless (not be responsible for payment). If the patient has a limited number of visits for a specific service (e.g., physical therapy), verify the number of visits left before or at the time of service. Collect the copayment from the patient at the time of visit. Patient Registration Information Specific information is necessary during the registration of a patient for you to submit a claim. Your office s frontline staff is vital to the success of the billing staff. Below is a summary of information that needs to be collected through your registration staff. Much of this information is documented on the patient s member card. Patient name Patient DOB and sex Patient s address Patient s relationship to the subscriber Subscriber name Subscriber DOB and sex Subscriber address Subscriber identification number with three-character prefix Name/type of product or insurance

9 Billing Information In order to submit claims, you will also need the following information: Date of service Place of service Procedure code Diagnosis code Number of days/units Charges Your tax identification number Provider name and address NPI number Group NPI number (if applicable) Taxonomy code Referring Providers If you are a referring provider, please ensure that your provider information, including address and specialty, are kept up to date on the National Plan and Provider Enumeration System (NPPES) registry at As a referring provider, your information may be important in the processing of claims for other providers or entities (example: location of the referring provider determines which Blues plan processes claims for laboratory services)

10 A.3 Course A Review Answer the questions below based on what you learned in Course A. 1. Who do you contact regarding electronic claim submission? 2. Give the address for submitting paper claims. 3. What is your claim timely filing limit? 4. What information should your registration staff collect? 5. What additional information do you need to submit a secondary claim? 6. What does Coordination of Benefits (COB) mean? 7. Can you submit secondary claims electronically? 8. How do you know if a claim has been crossed over from Medicare?

11 Course B Paper Claims Optical Character Recognition...B Claim Form...B.2 UB-04 Claim Form...B.3 Helpful Hints for Coding & Billing...B.4 Course B Review...B

12 B.1 Optical Character Recognition As mentioned in Course A, paper claims must be submitted on the CMS-1500 claim form for professional providers and UB-04 claim form for institutional providers. A combination of optical character recognition (OCR) and human intervention is used to scan all paper claims, and claims without required information will be mailed back to you. Optical Character Recognition Used to scan and enter paper claims into the claims processing systems. Improves quality and the time it takes to process a claim. Is available for us to view when you call with questions. Shows the exact claim you submitted in a matter of minutes. Remember, submitting claims electronically is preferred. You should only submit paper claims if you have a waiver or if it is not possible to submit the claim electronically. OCR Front End Edits As with electronic billing, the following are reasons why a paper claim may be rejected back to you for corrections. B.2 CMS-1500 Claims: Form illegible or wrong form type Omitted subscriber ID# (box 1a) Omitted patient name (box 2) Omitted date of birth (box 3) Omitted diagnosis code (box 21) Omitted date of service (box 24A) Omitted place of service (box 24B) Omitted procedure code (box 24D) Omitted charges (box 24F) Omitted provider tax ID# (box 25) Omitted NPI Individual (Box 24J) Omitted Group or Solo NPI (Box 33A) Omitted taxonomy code Additional OCR Hints for CMS-1500 Submitters: Use the original CMS-1500 forms that are printed in red. Do not use photocopies. Do not use red ink to fill data fields or attachments. OCR does not read anything in red. Do not use highlighter on the form. Type - do not handwrite, in the boxes on the form. And do not write outside the box lines. For Box 33, include only the provider name, address, and provider NPI number and taxonomy code. Change the toner in your printer regularly. OCR does not read faded print

13 Mailing Address for Paper Claims: Excellus BlueCross BlueShield Claims PO Box Eagan, MN, Sample 1500 Claim Form (02-12) Instructions on form completion are available via the NUCC website:

14 B.3 UB-04 Claim Form The UB-04 is the standard claim form to bill when a paper claim is allowed for institutional providers. Institutional providers include hospitals, skilled nursing facilities, home health agencies, hospices, outpatient rehabilitation clinics, outpatient rehabilitation facilities, community mental health centers, Indian health service facilities, etc

15 B.4 Helpful Hints for Coding & Billing Web Tools Access our website, ExcellusBCBS.com/ProviderCodingBilling, for an array of helpful coding and billing tools. Here s what you ll find online: Clinical Editing: We have implemented ClaimsXten, an enhanced clinical editing solution. It s a valuable tool that: improves the accuracy of payment policy application provides enhanced technical functionality improves overall claims management assists with maintaining a consistent payment policy in alignment with state and national mandates Clinical Editing Review Request: If you feel that a clinical editing denial has been made in error, you may submit a Clinical Editing Review Request. This can be done online through our Clinical Editing (CE) Dispute tool, available at ExcellusBCBS.com/ProviderCodingBilling, or by completing our Clinical Editing Review Request paper form (located at ExcellusBCBS.com/ProviderContactUs > Print Forms). We review all requests within 45 business days of receipt and will provide you with a response to your inquiry within that 45-day time frame. Note: You have within 120 days of remittance advice reciept to submit this request. Claims Filing: Electronic Submission Procedure Code Modifiers Request for Timely Filing Review (PDF) Request Claim Adjustment Also: Clinical Editing Communications, Fee Schedules, Coding Tips and Information, Medical Record Submission Information, ICD-10 and HIPAA Resources, Sign Up for EFT, Adjustment Requests and more

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17 B.5 Course B Review Answer the questions below based on what you learned in Course B. 1. When you submit a paper claim, what process is applied? 2. What are the benefits of this process? 3. Give five reasons why a CMS-1500 claim would be rejected back to you through OCR. 4. How do you identify mandatory fields for a CMS-1500? 5. In what field on the CMS-1500 claim form is the NPI number printed? 6. If you are submitting a secondary balance, what fields must be completed?

18 Course C Electronic Claims Electronic Claim Clearinghouse...C.1 Electronic Claim Processing...C.2 Common Rejections for Electronic Claims...C.3 Course C Review...C

19 C.1 Electronic Claim Clearinghouse Electronic claim submission is the fastest, most efficient way to submit claims for reimbursement. In addition to its many advantages, electronic claim submission is mandated by New York State Public Health Law. The Excellus BCBS clearinghouse allows submitters to electronically transmit claims using the standard ANSI claim formats (837I for institutional claims, 837P for physician/medical claims and 837D for dental claims). A submitter is defined as a provider in the Excellus BCBS service area, a clearinghouse or a third party supplying billing services. Our EDI department maintains our clearinghouse. How Does the Clearinghouse Work? The clearinghouse receives claim files through a Secure File Transfer Protocol (SFTP). The clearinghouse then applies the appropriate editing to validate the inbound files. Finally, the clearinghouse sorts and routes the accepted claims to the appropriate payers and payer systems. Claims that fail at the validation level are returned via SFTP to the submitter on a TA1 clearinghouse report for correction and resubmission. The status for all claims sent to our clearinghouse will be returned via SFTP to the submitter on the 999, 277CA and Payer Response reports as accepted or rejected. Any rejected claims will need to be corrected and resubmitted. Once the claims have been passed to the appropriate payers and they have been accepted into the payer Security: system for adjudication, all communication related to the adjudication of the claims will be between the payer and the provider. The clearinghouse environment is protected from unauthorized access using user IDs and passwords. Access is restricted through unique profiles that reflect each user s needs. EDI Solutions Support Assistance: EDI Solutions is available to assist with problems that you may experience with the clearinghouse. You may contact EDI Solutions for questions regarding: 1) How to become an electronic biller. 2) If you are an electronic biller, questions regarding your claim transmission or any rejections. EDI Solutions edi.solutions@excellus.com Registration: To enroll for electronic file submission, go to and select Vendor Resources. Complete and submit an Electronic Consent form. If you will be submitting claims through a billing agency or clearinghouse, contact them directly. Do not submit an Electronic Consent form. In addition, claim testing must be successfully completed before production is certified

20 C.2 Electronic Claim Processing Electronic Claims Submission Excellus BCBS works closely with electronic billing vendors to accommodate the testing of their software. Once testing has shown that the vendor has met the necessary specification requirements, electronic billing can begin through the vendor s software. Submitting Electronically: Submitters may transmit files to the clearinghouse 24 hours a day, seven days a week. There is no limit to how many files can be transmitted on a given day. Limit files to 5,000 claims. Claims accepted by the clearinghouse will be transmitted to the appropriate payers within 24 hours. Holiday Processing: You may transmit an electronic claim file on a holiday. The file will be processed and clearinghouse reports will be generated. If the holiday is a two-day holiday, you may transmit on both days and retrieve your clearinghouse reports. If you do not receive a clearinghouse report, you will need to contact ecommerce on the next business day. Do not transmit the same file again. Claim Validation and Editing: First step in the clearinghouse process Applies high level edits such as: - verification that mandatory fields/required records and fields have been populated - numeric/numeric checks - field length checks - code validation Performs editing at four levels: - File level: If an error is encountered at the file level, the clearinghouse will reject the entire file and will report this on the TA1 clearinghouse report. - Batch level: If an error is encountered at the batch level, the entire batch will be rejected. This will be reported on the 999 and 277CA clearinghouse reports. - Claim level: A claim level error will result in rejection of that claim and be reported back to the submitter on the 999 and 277CA clearinghouse reports. Claims that are accepted by the clearinghouse continue through the claim distribution function to be routed to the appropriate payers

21 - Payer level: A payer system error will result in rejection of the claim. This will be reported on the Payer Response report. This is a proprietary report that is also known as the NYSCOP report. Claim Distribution: The claim distribution function sorts the accepted (clean) claims by payer. Claims are bundled into files that are transmitted to the payer system where payer specific editing is performed. Payer Response reports are generated. Helpful Clearinghouse Information for Electronic Claims: The ISA06 (sender id) and GS02 (sender code) values in the header of claim files will be validated. These values are not the Tax ID. They are the assigned Submitter ID provided during the electronic enrollment process with BCBS. Duplicate file checking will be based on the interchange control number which is the value found in the ISA13 field of the claim file. This value must be unique on every file submitted (including corrected/resubmitted files) or the file will be rejected. The production/test indicator that is located in the ISA15 field will be edited. If a test indicator is submitted on production files, the files will be rejected. Claim file submission history will be available for six months online. When billing Lifetime Benefit Solutions claims, LIFETIME BENEFIT SOLUTIONS, INC must be included in loop 2010BB, NM103 to ensure claims are routed properly. If the Payer name (as mentioned above) cannot be changed then the Plan Code/Payer ID in loop 2010BB, NM109 must equal one of the following: RMSCO, EBSRM or Each submitted claim file should have a unique file name

22 C.3 Common Payer System Rejections for Electronic Claims Misrouted Claim (through the ITS system) - Most likely the prefix on this claim is incorrect. - Contact the patient or use the web to obtain the correct prefix information. Special Characters in the Insured s First or Last Name Not Allowed - The claim you are submitting has hyphens or apostrophes in the name. - Only characters are allowed. - Enter the name exactly as it appears on the member card. Patient Sex or Birthdate does not Match Membership - The patient s sex or birthdate you have entered on the claim does not match our membership. - One of the two systems is incorrect - if it is your data, correct the information and resubmit. - If it is our data, please have the patient contact us to correct our information, and then you will be able to resubmit the claim. No Coverage Located on Membership - With the information you have submitted, there is no active or terminated coverage found. - You may receive this message if you used an incorrect prefix and the claim hits against the wrong system. - Verify with the patient their insurance coverage information. Medicare Claim Out of Balance - Information is incorrect with your primary payment information and the payment that you are seeking. - Contact your vendor to correct the appropriate fields for secondary claims. Terminated CPT/HCPCS or Procedure Code - The procedure code that you submitted is terminated within the payer system. - Investigate if a new code has been implemented by CPT/HCPCS. Please be aware that if a claim is rejected on an electronic report, Excellus BCBS will not have the claim on file and as such, it will not be processed. In this situation, you will need to resubmit the claim(s). Electronic error reports should be handled in the same way that you would troubleshoot a paper remittance

23 C.4 Course C Review Answer the questions below based on what you learned in Course C. 1. What is the name and telephone number of the department that is responsible for electronic claim submission? 2. How often can a submitter transfer files to the Excellus BCBS clearinghouse? 3. Can a submitter transfer files on a holiday? Explain the process. 4. What are the names of the two reports received when claims are submitted electronically? 5. When is the clearinghouse report available for review? 6. What is the payer report and when is it available for review? 7. What is the most vital step of submitting claims electronically? 8. What does a misrouted claim through the ITS system indicate?

24 Course D Provider Remittances Excellus BCBS Remittance Highlights...D.1 Remittances...D.2 Course D Review...D

25 D.1 Excellus BCBS Remittance Highlights Below are highlights that apply to all remittances received from Excellus BCBS. This includes reimbursement, recoupment and electronic code reviews. Reimbursement Highlights Paid-in-Full and Hold Harmless: We pay participating providers directly for covered services. You accept our payment as payment-in-full and have agreed to not collect from or bill our member. However, make sure you collect the copayment, coinsurance, deductible and member penalty when applicable. Fee Schedules: Excellus BCBS uses the Resource-Based Relative Value Scale (RBRVS) as an aid in developing and maintaining our fee schedules. Fee schedules may vary by product (Commercial, Medicare Advantage, Government Programs and Special Programs) Fee schedules are available on our website and updated annually for physicians. To access, you must login with your Excellus BCBS website username and password as this information is housed on a secure section of our website. Go to ExcellusBCBS.com/ProviderCodingBilling > Fee Schedules. In addition to your website login password, a regional password is required to access Fee Schedule information online. The password is provided to your office in our annual Fee Schedule Update notice, which is mailed at the end of December. If you need password assistance or cannot find the notice, contact your Provider Relations representative. Recouping Incorrect Payments: In the event that Excellus BCBS makes an incorrect payment or an overpayment, our provider contracts allow us to make necessary and appropriate adjustments in the form of offsets and/or retractions from future payments. In some cases, you will receive a 30-day notice of retraction. Electronic Code Review: Excellus BCBS uses an electronic code review system. This system evaluates billing information and determines the accuracy of the CPT and ICD coding. This system allows us to keep pace with the changing medical technology and to assure accuracy in our payments to providers. With this electronic code review system, we are able to evaluate bills and correct those claims that have been incorrectly coded

26 This system is designed to evaluate claims to detect irregularities such as: Unbundling: - Providers are to bill for services using the most inclusive CPT coding that accurately describe the services rendered, rather than billing under several individual CPT codes that should be combined under a single charge. For example, CPT procedure is for a total hysterectomy including removal of tubes and ovaries. There are separate codes for each of these procedures hysterectomy, removal of tubes and removal of ovaries. If all three were billed as separate lines with separate CPT codes, our electronic code review would rebundle them to Incidental Procedures: - Procedures carried out at the same time as a primary procedure and which require little additional physician resource, and/or are clinically integral to the performance of the primary procedure should not be billed separately. For example, if a patient undergoes a gastrectomy (43620 removal of all or part of the stomach), other abdominal procedures would be considered incidental. Mutually Exclusive Procedures: - Defined as the billing of two or more procedures that, by medical practice standards, would not be billed on the same patient, on the same date of service. For example, vaginal hysterectomy and total abdominal hysterectomy would be considered mutually exclusive. Clinical Editing: From ExcellusBCBS.com/ProviderCodingBilling > Clinical Editing

27 D.2 Remittances As a participating provider, you may receive different types of provider remittances (remits) or Explanation of Benefits (EOB). See below for details. Facets Remittance: Remittances and checks are processed on a weekly basis. Professional and facility claims are processed on Facets. ID numbers currently on the Facets system begin with a three-character prefix and a nine-digit number beginning with 200, 201 or M20. The activity summary page will be the first page of each remittance. Electronic Remittances: You can choose to receive your remits electronically in place of paper remittance. Contact your vendor to receive your electronic remittance from our clearinghouse. Electronic Remittance Advice (ERA) and Electronic Funds Transfer (EFT): Excellus BCBS partners with InstaMed to offer Web-based ERAs and EFTs. For more information, call , or visit our website, ExcellusBCBS.com/wps/portal/xl/prv/adm/br/electpay/. Note: To visit the InstaMed website directly, go to

28 Remittance Samples Electronic Remittance Payment Remittance Detail

29 Paper Remittance

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31 D.3 Course D Review Answer the questions below based on what you learned in Course D. 1. Name four reimbursement fields that apply to Excellus BCBS remittance. 2. How do you identify the line of business of the payment on the remittance? 3. Where are the denial reasons located on a remittance? 4. What s an important field on the remittance that you should review when your remittance and checks do not balance? 5. What does ERA stand for? What does EFT stand for?

32 Course E Troubleshooting Outstanding Claims Requesting Claim Adjustments...E.1 Examples of Claim Adjustments...E.2 BlueCard Claim Adjustments...E.3 Clinical Editing Denials...E.4 Involving the Member...E.5 Maximizing Receivables... E.6 Course E Review...E

33 E.1 Requesting Claims Adjustments Excellus BCBS has a claims adjustment process that providers may initiate after the claim has been processed. Claim Adjustment Requests: Common reasons for claim adjustments include: - An overpayment where you need to request that Excellus BCBS retract the overpaid monies. - A claim denied incorrectly, where a retraction and reprocessing may be necessary. - A submission of a corrected claim that denies as a duplicate claim in error. In these cases, you will need to request that the claim is reprocessed or you may need to submit a corrected claim. Methods to Request Claims Adjustments Online Adjustment Requests (for local claims): Go to ExcellusBCBS.com/ProviderCoverageClaims > Request Claim Adjustment > Submit a Claim Adjustment Online. Note: You must be a registered website user (have a username and password) to access this tool. Enter the requested information in the fields (e.g., subscriber ID, DOB, NPI) When you have successfully located the claim, select the claim for more details and you will see a link to the online adjustment form. If the claim has not been reprocessed after 30 days, contact Customer Care for a status update. Paper Claim Adjustment Form: The Claim Adjustment or Retraction Request form is available via our website, ExcellusBCBS.com/ProviderContactUs > Print Forms. If you do not have web access, contact Customer Care to obtain a paper copy. A sample of the form is included in this training guide. If the claim has not been reprocessed after 30 days, contact Customer Care for a status update. Call Customer Care at : When you call Customer Care, be sure to have the following information: Your tax identification number Patient s identification number Date of service Details of your adjustment request If your adjustment can be completed, the Customer Care Advocate will request that the claim be reprocessed. This may take two to four weeks for a local claim and possibly longer for an out-of-area claim. If the claim has not been reprocessed after 30 days, contact Customer Care for a status update

34 E.2 Examples of Claim Adjustments Claim Reprocessing and Adjustment Requests Overpayments or Credit Balances: If you received an overpayment from Excellus BCBS, the easiest way to remedy the account is to request a retraction. This can be done through any of our adjustment methods. You will see the retraction on a future remittance and future monies will be held to cover the money owed. For COB claims, where Excellus BCBS paid as a primary and should have been secondary, there is a possibility that the patient has not informed us that another carrier is primary. Claims will continue to pay as primary until the patient contacts us with the correct information. Claims Denied Incorrectly: There may be times when claims are denied in error. Examples: A claim that denied as a duplicate even though only one claim has been submitted; a claim that denies for no authorization even though an authorization is on file. You can request that these claims be reprocessed through any of our adjustment methods. Claims that Deny and Require Follow-Up: Denials Showing Additional Information Needed: - Name of referring provider is needed to request medical records. - Need information from the member, such as dependent or COB information. Denials Showing No Coverage Found (but you know the member has coverage): - Verify that the correct prefix was used to submit the claim. - Verify that you have the correct patient information (name, DOB, etc.)

35 This form can be accessed via our website at ExcellusBCBS.com/ProviderContactUs > Print Forms

36 This form can be accessed via our website at ExcellusBCBS.com/ProviderContactUs > Print Forms

37 This form can be accessed via our website at ExcellusBCBS.com/ProviderContactUs > Print Forms

38 This form can be accessed via our website at ExcellusBCBS.com/ProviderContactUs > Print Forms

39 This form can be accessed via our website at ExcellusBCBS.com/ProviderContactUs > Print Forms

40 This form can be accessed via our website at ExcellusBCBS.com/ProviderContactUs > Print Forms

41 E.3 BlueCard Claim Adjustments BlueCard links participating health care providers and BCBS plans across the country and around the world through a single electronic network for claims processing and reimbursement. The program allows your office to submit claims for patients from other BCBS plans directly to your local plan. Your local plan will be your contact for claims payment, problem resolution, adjustments and inquiries. Out-of-Area Claims Handled by the Home Plan: All out-of-area BCBS claims (including secondary claims) must be submitted to your local plan for processing. The local plan will pass the claims to the out-of-area plan (member s Home Plan) for processing. It is up to the member s Home Plan to decide if it will pass the claim back to the local plan for provider payment or if it will process the claim and pay the member. The above scenario typically only happens when the claim is secondary to Medicare. You will receive a denial code on your local remittance that the claim has been forwarded to the Home Plan for processing. You need to make these accounts self-pay, as it is likely that the subscriber will receive the check. Out-of-Area Claims Denied for Service Not Covered: When a claim denies as a non-covered service and the member is out-of-area, you must contact the member s Home Plan to verify benefits (and to confirm if the denial is correct). Out-of-area benefit information is not available in the Local Plan s system. If you are informed that the service should be covered, please contact the Local Plan to reprocess the claim as the Local Plan holds the claim on file that needs to be reprocessed. To contact a member s Home Plan, call BLUE and provide the three-character prefix. You will be connected to the Home Plan. Out-of-Area Claims Denied for No Authorization: If a service requires a preauthorization for an out-of-area member, an authorization must be on file with the member s Home Plan. If a claim denies for no authorization, you must contact the Home Plan to verify that an authorization is in place. If an authorization is in place, you need to contact the local plan to reprocess the claim

42 E.4 Clinical Editing Denials As part of the claims adjudication process, our claims systems will review a claim to determine that it fulfills our medical policies, referral requirements, preauthorization requirements and other benefit management specifications. Appeals for Clinical Editing Denials: Includes denials such as inclusive, mutually exclusive or rebundled claim lines. There are two scenarios applicable to these types of appeals see below. It s your responsibility to clearly advise which of the two circumstances applies to your case: 1. You are appealing a specific case due to unique circumstance Please provide a detailed synopsis of why the appeal is being requested, what is unique, and include medical records to verify your position. 2. You are appealing the editing software Please provide professional literature, scientific studies, publications, and/or references to prove the editing software is incorrect. You must use our online Clinical Editing (CE) Dispute tool or our Clinical Editing Review Request form for these types of denials. The dispute tool is located at ExcellusBCBS.com/ProviderCodingBilling and the form is available at ExcellusBCBS.com/ProviderContactUs > Print Forms. If you do not have web access, contact Customer Care for a paper copy of the form. Clinical editing appeals go through a review process and the outcome of the committee s decision will be relayed to you in writing. You have 120 days from the date of the remittance advice to request a claim review for clinical editing. This form, along with Clinical Editing Q & A, can be accessed via our website ExcellusBCBS.com/ProviderContactUs > Print Forms

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44 E.5 Involving the Member When to Involve the Member: It is your patient s responsibility to provide you with his/her insurance information. If the patient is unable to do this at the time of service, he/she is responsible for the bill until that information can be obtained. Once insurance information is obtained, you must submit claims on his/her behalf. If the claim is over the timely filing limit, you must submit the Request for Timely Filing Review form with the claim. The Request for Timely Filing Review form is available via our website, ExcellusBCBS.com/ProviderContactUs > Print Forms. If you do not have web access, you may request a paper copy of the form by calling Customer Care. Many times, patients will have copayments, coinsurance and/or deductibles that are applied and reduced from payment. We recommend that you collect copayments and deductibles at the time of service. Many providers act as a patient s advocate with the insurance company; however, when an insurer correctly denies a claim, it is best to advise the patient to call his/her insurer with questions. The telephone numbers for Customer Care (a.k.a Customer Service) are located on the patient s member card

45 E.6 Maximizing Receivables We recommend using your billing software and billing vendor to track problems with billing procedures and issues with insurance carriers. Tracking Reports Suggestions: Monthly Reports: - Aged receivables or outstanding receivables by carrier - Credit balances by carrier - Total outstanding for each carrier out of total charges billed and total payment expected Quarterly Reports: - In addition to your monthly reports, look at your top four carriers and track the following: - Average time between service date and claim submission date - Average time between claim submission and time remittance claim received - Average time between when remittance /claim received and time posted - Number of claims denied per carrier and top five reasons why - Number of claims rejected through electronic clearinghouse and top five reasons why - Number of claims being submitted on paper and top five reasons why Annual Reports: - Total revenue by carrier - Total revenue versus total amount charged and total payments expected - Amount outstanding by carrier out of total outstanding charges billed and total payment expected for these charges - Average time per carrier between date of service and time claim paid/denied - Number of claims denied per carrier and top five reasons why

46 E.7 Course E Review Answer the questions below based on what you learned in Course E. 1. Under what circumstances should a corrected claim be submitted? 2. Name three ways to request an adjustment? 3. What is the most efficient way to request an adjustment? 4. What should you do if a secondary claim continues to pay as primary? 5. Under what circumstances can medical records be requested before a claim is completed? 6. What should you do if a claim has been forwarded to the Home Plan for processing and it denied? 7. If an out-of-area claim denies as Non-Covered Service who should you call to verify that the denial is accurate? 8. What information is necessary to appeal a claim line denied inclusive? 9. Under what circumstances should you suggest that a patient call his/her insurance plan for clarification?

47 Course F Website Tools Website...F.1 Course F Review...F

48 F.1 Website Convenient Self-Service Visit the Excellus BCBS website, ExcellusBCBS.com/Provider, to see why more providers choose to click with us. From news and information to forms and formularies our website offers the resources and information you need, right at your fingertips! Save Time, Check Online Check claim status and request adjustments Check, enter, update and delete referrals Check member eligibility and benefits Enter an emergency admission View clinical review requirements Update practice information Review referral guidelines Request preauthorizations Read medical policies Review Provider Manuals Connect patients with health resources Access to prescription drug information medication guide, prior authorization forms, specialty pharmacy network Download forms interactive and can be completed electronically! And do much MORE! You must be a registered website user to have complete access to online tools and resources. Registering only takes a few moments. Visit ExcellusBCBS.com/Provider Scroll to Register Now! Select the role that applies from the I am a drop-down menu, then click GO Enter your information, then click Submit Login with your username and password Need Assistance Registering? Contact the Web Security Help Desk at Your Provider Relations representative is also available for training on Web registration and functionality. Excellus BCBS Online Registered providers login with your username and password! If you haven t registered, do it today! Select your position from the dropdown menu and complete the registration form. If you have questions, call our Web Security Help Desk at Registering ensures that you have complete access to our online tools and resources. Don t delay, register today!

49 Coding & Billing The Coding & Billing section of our website offers the following: - Clinical Editing Dispute - Clinical Editing Communications - Clinical Editing Policies - Fee Schedules - Procedure Code Modifiers - Medical Record Submission - Telemedicine - Claims Filing - Reading Your Remittance - ICD-10 Resources

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52 F.2 Course F Review Answer the questions below based on what you learned in Course F. 1. What is the website address to access the provider section of the Excellus BCBS website? 2. Which section of the website contains fee schedule information? 3. Can you sign up for EFT via our website? 4. Why should you Click Before You Call? 5. Can you obtain out-of-area member information via our website? 6. If you re a registered website user, do you have complete access to our online tools? 7. Who should you contact if you need assistance registering?

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