Dental Network Office Manual

Transcription

1 July 2008 Provider Network News 3 Dental Network Office Manual /ilinkblue July 2008 Provider Network News 3 23XX4296 R08/10 Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Services Indemnity Company

2 Blue Cross and Blue Shield of Louisiana DENTAL NETWORK OFFICE MANUAL This is your Dental Network Office Manual. It is designed it to be a complete reference guide for you and your office staff. It includes all the information you will need to know as a participant in Blue Cross Key, FEP and/or Discount Dental Networks only. To use your manual, first familiarize yourself with the Support and Filing Claims sections. From that point on, the Table of Contents should direct you to the information you need. Periodically, we send newsletters and informational notices to participating dentists. Please keep this information and a copy of your agreement along with your manual for your reference. Provider newsletters can be found the Provider page of our website at under Provider News. If you have questions about the information in this manual or your participation as a network provider, your participation as a Key, FEP and/or Discount Dentist, please call Provider Network Administration at , option 3. You may also contact your Network Development Representative, Paige Carriere at Paige.Carriere@bcbsla.com. Thank you for working with us to provide our members your patients with the best possible dental service and benefits. We appreciate your participation in our dental network(s). We look forward to working with you! Please note: This manual contains a general description of benefits that are available subject to the terms of a member s contract and our corporate medical policy. The Subscriber Contract/Certificate contains information on benefits, limitations and exclusions and managed care benefit requirements. It also may limit the number visits or dollar amounts to be reimbursed. This manual is provided for informational purposes only. Every effort has been made to print accurate, current information. Errors or omissions, if any, are inadvertent. CPT only copyright 2010 American Medical Association. All rights reserved. CDT Only American Dental Association Website/ 8 7 Call/Fax Mail ', 7 Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Blue Cross Company and Blue Shield of Louisiana Dental Network Office Manual P.O. Box 98029, Baton Rouge, Louisiana

3 Dental Network Office Manual TABLE OF CONTENTS Quick Reference Guide to Important Addresses and Phone Numbers 4 Section 1: Dental Network Overview 5 Introduction 5 Overview 5 Blue Cross Members With Key Dental benefits 6 Federal Employee Program (FEP) Dental benefits 6 Blue Cross Members With Discount Dental benefits 7 How do Blue Cross members get information about participating dentists? 7 Provider Information Changes 7 Provider Directories 8 Refer Members to Network Providers 8 Provider Update Request Form 9 Section 2: Dental Billing Guidelines 11 General Guidelines 11 Claims Filing Process for Non-Surgical Claims 11 Claims Filing Process for Oral Surgery Claims 11 Intravenous Sedation 12 Multiple Surgical Procedures 12 Orthodontia Work in Progress 12 Nitrous Oxide 12 Alternative Dental Procedure Payment Responsibility Form Explanation 13 Alternative Dental Procedure Payment Responsibility Form 14 Section 3: Claims Submission 15 How to File Dental Insurance Claims 15 Using CDT Codes 15 National Provider Identifier (NPI) 15 Claims Mailing Addresses 16 Tips for Submitting BlueCard (Out-of-State) Claims 16 ADA Dental Claim Form 17 CMS 1500 Health Insurance Claim Form 20 Section 3-A: Electronic Claims Submission & Payment 24 Electronic Data Interchange (EDI) 24 ilinkblue Provider Suite 24 Electronic Remittance Advice/Payment Register 24 Electronic Funds Transfer (EFT) 25 EFT Application 26 Section 4: Reimbursement 27 Allowable Charges 27 Maximum Allowable Charge 27 Discount Dental Charge 28 Cancellations and No-shows 28 Coordination of Benefits 28 Legacy Weekly Provider Payment Register/Remittance Advice 29 Facets Weekly Provider Payment Register/Remittance Advice 31 Blue Cross and Blue Shield of Dental Network Office Manual 2

4 Section 5: Appeals 33 Informal Reconsideration 34 Appeals Process for Non-ERISA Members (MNRO) 34 Appeals Process for ERISA Members 36 FEP Reconsiderations and Appeals Process/Guidelines 38 External Review of Billing Disputes 39 Section 6: Frequently Asked Questions 40 Section 7: Communicating with Blue Cross 42 Electronic Benefit Verification 42 Provider Services Voice Response Telephone System Call Center 42 Customer Service 43 Preadmission Authorization 43 Provider Network Administration 43 Provider Relations Services 43 Section 8: Definitions 44 3

5 Quick Reference Guide to IMPORTANT ADDRESSES AND PHONE NUMBERS ', Provider Services Voice Response Telephone System (Call Center) Option 1 - Fax or voice summary of benefits or claim status Option 2 - Calling to set up a new authorization Option 3 - Out-of-state policy Option 4 - Federal Employee Policy (FEP) Option 5 - All other calls - Network Administration Provider Network Administration Network.Administration@bcbsla.com Participation/Contracting/Credentialing Questions: or Provider Relations: FEP Customer Service: Claims Addresses All completed claim forms should be forwarded to the following addresses for processing: Blue Cross and Blue Shield of Louisiana P. O. Box Baton Rouge, LA FEP claims should be mailed to: Blue Cross and Blue Shield of Louisiana FEP Claims P. O. Box Baton Rouge, LA Electronic Services /ilinkblue ilinkblue.providerinfo@bcbsla.com BLUE (2583) LINK (5465) EDI Clearinghouse EDICH@bcbsla.com Please identify yourself as a participating dentist when contacting us. BlueCard Eligibility Line BLUE (2583) Member Benefits Call the number on the member s ID card. Fraud & Abuse Hotline Appeals and Grievances/Provider Dispute Resolution Blue Cross and Blue Shield of Louisiana Appeals and Grievance Department P. O. Box Baton Rouge, LA or Fax Blue Cross and Blue Shield of Dental Network Office Manual 4

6 Section 1 DENTAL NETWORK OVERVIEW Introduction Blue Cross and Blue Shield of Louisiana offers three dental networks. The Key, FEP and Discount Dental Networks are networks of dentists linked together through a business relationship with Blue Cross. These networks emphasize the vital healthcare roles of the dentist and Blue Cross, and are designed to create a more effective business relationship among dentists, consumers and Blue Cross. Freedom to choose The Key and FEP Dental Networks place no disincentives or restrictions on dental benefits. Members can continue to select their own dentist. However, members who choose non-participating dentists may have to file their own claims and will be responsible for paying the dentist for all charges, including any difference between the Blue Cross allowable charge and the fee charged by the dentist. The Discount Dental Network allows Blue Cross members without dental benefits access to participating dentists. Members receive materials outlining the advantages of using the services of network dentists and a directory that lists participating dentists by location. As a participating dentist, you agree to accept the Blue Cross payment, plus the member s deductible and coinsurance, as payment in full for covered services. In return you receive prompt and direct payment from Blue Cross. For those dentists who choose not to become Key or FEP Dentists, payment will be made directly to the member. Gives patients predictable out-of-pocket expenses Blue Cross members have predictable out-of-pocket expenses when they use the services of a participating dentist. Additionally, they can be secure in the knowledge that the business transaction of efficient claims filing and prompt claims payment is being taken care of by their in-network dentist and Blue Cross. Overview This office manual is for you and your staff to use in handling claims for your Blue Cross patients. As a participant in the Blue Cross Key and/or FEP Dental Networks, you have agreed to: Accept the Blue Cross payment, plus any member deductible, coinsurance and/or copayment if applicable, as payment in full for covered services File claims for Blue Cross members Please be aware that our member contracts have different maximums, deductibles and percentage of benefits payable. If you have questions about benefits or eligibility, you can check this information by contacting Provider Services at or through ilinkblue, our free online provider tool (for more information on ilinkblue, see the Support Section of this manual). 5

7 Blue Cross Members With Key Dental Benefits All members who access this network can be identified by the Cross and Shield logo on their ID cards and the words Key Dental Network below the member s name. You should request that patients show you their card each time they visit your office. The information on the ID card can be used when submitting claims, making claims inquiries, obtaining coverage and verifying benefits. Please Note: There are certain Blue Cross members who DO have dental benefits but who DO NOT have access to the Key or FEP Dental Networks. These members are not subject to the terms and conditions of the Participating Dental Agreement. If they do not access the Key or FEP Dental Networks, you may bill them for any amounts over our allowable charge and are not required to file claims on their behalf. In some instances, self-funded, Administrative Service Only (ASO) groups may not be limited to Key Dental Allowable Charges. Please call the number on the member s ID card to determine if you are entitled to collect in excess of the Key Allowable Charges. Federal Employee Program (FEP) Dental Benefits The FEP Preferred Dental Network provides dental services for Federal Employee Program (FEP) members. You can identify FEP Dental Network members by their ID cards. The member identification number will always begin with R. Similar to the Key Dental Network, the FEP Dental Network offers: Fee-for-service reimbursement Workshops and in-service sessions Direct payment Toll-free number for benefits and claims questions Inclusion in the Service Benefit Plan Directory of Network Providers Participants in the FEP Preferred Dental Network agree to accept the FEP Maximum Allowable Charge (MAC), which includes Blue Cross payment and member liability, as payment in full for covered dental services. Refer to the Reimbursement Section of this manual for additional reimbursement information. Blue Cross FEP members can choose between Standard and Basic Option benefits: Standard Option Greater benefits Blue Cross reimburses FEP Dentists up to the Fee Schedule Amount. Member pays the difference between the Fee Schedule Amount and the maximum allowable charge (MAC)* *MAC is the total combined amount a Preferred Dentist can collect from Blue Cross and the FEP member. 6

8 Basic Option Limited benefits No benefits for non-fep dentists $20 copayment If you have any questions about Blue Cross FEP Preferred Dental Network, please call our FEP Customer Service Unit at Blue Cross Members With Discount Dental benefits Our Discount Dental Network is a special network for Blue Cross members who do not have a dental benefit plan (members will present their medical ID cards). Dentists participating in the Discount Dental Network agree to collect a predetermined amount from Blue Cross members at the time services are rendered. Because this is not a benefit plan, there are no claim forms to file. Participating dentists simply collect the predetermined amount, which is listed in the Dental Services Discount Agreement, from their Blue Cross patients. To participate in the Discount Dental Network, dentists must sign the Dental Services Discount Agreement, which is separate from the Participating Dentist Agreement. How do Blue Cross members get information about participating dentists? As a participating dentist, your name is included in the Blue Cross Key, FEP and/or Discount Dental Network Directory(ies) distributed to all members and may be viewed at. Participating dentists are listed in the directory in alphabetical order by parish and specialty. Provider Information Changes If you have changes in your name, telephone number, address, tax ID, specialty or group practice, please fill out a Provider Update Form on line: Visit our website at, click on Provider, then on Forms for Providers, then choose Provider Update Form. You may also call Network Administration at , option 3 or, you may fill out the form on the next page and mail it to the following address:, 7 Blue Cross and Blue Shield of Louisiana ATTN: Network Operations P.O. Box Baton Rouge, LA Fax: Online Provider Update Form Provider u Forms for Providers Please report any changes in your listing immediately. We update our Key Dental Network Directory regularly and continually update our master file to maintain current, accurate information on all providers. 7

9 Provider Directories As a participating provider, your name is included in the Blue Cross product-specific provider directories, which are distributed to all subscribers and featured at our website,. Participating providers are listed in the directories by parish in alphabetical order under their specialty(ies). Thousands of healthcare professionals and facilities across the state are in our networks. You can find the one you need quickly with our easily searchable directory. Listings are updated daily. We make every effort to ensure the information in our provider directories is current and accurate. Please notify Provider Network Administration in writing, if you have one of the following changes occur: have a change in contact information new providers join your practice obtain an new tax ID number providers in your clinic retire or move you close/merge a practice A Provider Update Request Form is provided in this manual and can be used to notify us of changes or additions to provider directories. You may also complete the update form online at under Provider, Forms for Providers. Select the Provider Update Form form from the list and fill in the blanks. You may notify us of a change by contacting us through the following ways as well: ' , option 3 Network.Administration@bcbsla.com (fax) Please note: Blue Cross cannot guarantee the continuing participation of providers listed in the online directories. Providers with multiple locations may not participate at all locations. Facility-based physicians may not be contracted healthcare providers. 7 Online Provider Update Form Provider u Forms for Providers Hardcopy Provider Update Form Copy the form on the next page and submit it as directed. u Refer Members to Network Providers As a participating provider in our networks, you agree to assist us in our efforts to keep our members costs down. One way to do that is to refer our members your patients to other participating providers. Referring to participating providers is important because members may pay significant costs when using a non-participating provider. The amounts that some non-participating providers charge for their services are higher than the negotiated fees participating providers have agreed to accept. When seeing a non-participating provider, the member may be responsible for the difference between the allowed amount and the billed charge. In the interest of affordable, quality care for your patients, it is important that you refer your Blue Cross patients to participating providers. To confirm if a provider is participating, please consult our online directories at. 8

10 Use this form to give Blue Cross and Blue Shield of Louisiana the most current information on your practice. Updates may include tax identification number changes, address changes, etc. Please type or print legibly in black ink. If you need more space, attach additional sheets and reference the question(s) being answered. GENERAL INFORMATION PROVIDER UPDATE REQUEST FORM Provider s Last Name First Name Middle Clinic Name Tax ID Number Clinic s National Provider Identifier (NPI) Office Hours Age Range Provider s National Provider Identifier (NPI) Name of Individual Completing This Form Phone Number Fax Number BILLING ADDRESS (address for payment registers, reimbursement checks, etc.) Former Billing Address City, State and Zip Code Phone Number New Billing Address City, State and Zip Code Phone Number Fax Number Address Effective Date of Address Change MEDICAL RECORDS ADDRESS (address for medical records request) Former Medical Records Address City, State and Zip Code Phone Number New Medical Records Address City, State and Zip Code Phone Number Fax Number Address Effective Date of Address Change CORRESPONDENCE ADDRESS CHANGE (address for manuals, newsletters, etc.) Former Correspondence Address City, State and Zip Code Phone Number New Correspondence Address City, State and Zip Code Phone Number Fax Number Address Effective Date of Address Change 23XX7231 R05/08 Blue Cross and Blue Shield of Louisiana Incorporated as Louisiana Health Service & Indemnity Company 9

11 PHYSICAL ADDRESS CHANGE Former Physical Address City, State and Zip Code Phone Number New Physical Address City, State and Zip Code Phone Number Fax Number Address Effective Date of Address Change TAX IDENTIFICATION NUMBER CHANGE Former Clinic/Group Name Former Tax ID Number Through Date of Former Tax ID Number New Clinic/Group Name New Tax ID Number Effective Date of New Tax ID Number Please attach a copy of your new IRS Employer Identification Number Letter NETWORK TERMINATION Terminated Network Effective Date Provider Number Tax ID Number Reason for Termination NETWORK TERMINATION (all networks) Terminated Address City, State and Zip Code Phone Number Provider Number Tax ID Number Reason for Termination Effective Date Please return this form to: Attn: Network Operations Blue Cross and Blue Shield of Louisiana P.O. Box Baton Rouge, LA (225) (fax) If you have any questions about this form, please call Network Operations at: (800) , Option 3 (225) (Baton Rouge Area) 23XX7231 R05/08 Blue Cross and Blue Shield of Louisiana Incorporated as Louisiana Health Service & Indemnity Company 10

12 Section 2 DENTAL BILLING GUIDELINES Blue Cross has provided the following billing guidelines to assist you with filing your dental claims. Please follow these guidelines regardless of whether the claim pays under the member s major medical benefit or the member s dental benefit. General Guidelines When filing Current Dental Terminology (CDT) codes, please use the 2006 American Dental Association (ADA) claim form. Do not file both an ADA claim form and a CMS-1500 claim form for the same service. We will reject the second claim as a duplicate claim. Do not list both the CDT and Current Procedural Terminology (CPT) code for each service on a claim form. When both CPT and CDT codes are listed, it is our policy to process the claim using the CDT code. File your actual charge. Allowable charges are provided for informational purposes, and they are not intended for use in establishing fees. Do not file OSHA charges separately. OSHA charges are included as an integral part of the procedures performed on the same date of service. There is no member liability for OSHA charges. Claims Filing Process for Non-surgical Claims Non-surgical claims must be filed with the appropriate CDT code. Non-surgical procedure claims filed with CPT codes will be returned to the dentist for proper coding. Due to contract limitation criteria, if you report prophylaxis and fluoride services on the same date, as one procedure (e.g. D1201 or D1205), the claim could be rejected. When reporting these claims, file them separately to ensure that you receive full benefits. When filing code D9630, include the name(s) of the drug(s) used (Block 30 of the ADA form). Claims Filing Process for Oral Surgery Claims Oral surgeons may bill either CPT or CDT codes for major oral surgical procedures. CPT codes must be billed on the CMS-1500 claim form. If CPT codes are billed on an ADA Dental Claim Form, the claim will be returned for the appropriate claim form. Oral surgeons may also bill for medical Evaluation and Management (E&M) services only when associated with major oral surgical procedures as appropriate. Claims for these services must be filed on a CMS-1500 claim form. Appropriate CDT codes must be billed when performing extractions. If CPT codes are submitted for extractions, the claim will be returned for appropriate CDT code(s). Any and all services related to impacted teeth must be filed with diagnosis code This includes all surgical and nonsurgical procedures. Claims filed for office visits and x-rays with diagnosis code 524.3, but without a primary procedure code, must have a brief description of services that will be rendered (Block 30 of the ADA form). If there is no description, the claim will be rejected. Do not file CPT code for surgical services, such as extractions. Any claim filed with CPT code will be returned for the appropriate CDT code. CPT codes and are described as single reconstructive procedures that do not allow for the billing of multiple units based on the number of implants placed. However, when billed with modifier 22, additional reimbursement will be considered when documentation with the number of implants is submitted. CPT only copyright 2010 American Medical Association. All rights reserved. 11

13 Intravenous Sedation When billing for intravenous sedation, dentists and oral surgeons should bill the appropriate CDT codes (D7210, D7220, D7230, D7240, D7241 and D7250) for the removal of impacted wisdom teeth in conjunction with the following sedation code guidelines: Bill CDT code D9220 for the first 30 minutes of deep sedation/general anesthesia. Bill CDT code D9221 for each 15 minute increment following the first 30 minutes of deep sedation/general anesthesia. Bill code D9241 for the first 30 minutes of intravenous conscious sedation. Bill CDT code D9242 for each 15 minute increment following the first 30 minutes of intravenous conscious sedation. Do not use CPT codes or as your claim will be returned for the appropriate CDT code. Multiple Surgical Procedures Multiple surgical procedures are those performed during the same operative session. Bilateral procedures are considered multiple procedures. When multiple procedures are performed, the primary or major procedure is considered to be the procedure with the greatest value based on the allowable charge and may be reimbursed up to the allowable charge. The CPT code modifier used to report multiple procedures is 51. The CPT code modifier to report single and multiple bilateral procedures is 50, see below for more information on modifier 50. Secondary covered procedures are reimbursed up to 50 percent of the allowable charge. Extractions of impacted teeth are not subject to multiple surgery reduction. If a service includes a combination of procedures, one code should be used rather than reporting each procedure separately. If procedures are coded separately, Blue Cross may recode the procedures and apply the appropriate allowable charge. Modifier 50 - Billing Single Bilateral Procedures Single Bilateral (Modifier 50) procedures can anatomically be done bilaterally only once per session. Multiple Bilateral (Modifier 50) procedures can anatomically be done bilaterally multiple times per session. Correct submission of a bilateral procedure is the code on one line with Modifier 50 and 1 in the units field. For all professional and facility claims, bilateral procedures are reimbursed as follows: 1) The primary bilateral procedures are reimbursed at 150 percent of the allowable charge. 2) The secondary bilateral procedures are reimbursed at 75 percent of the allowable charge. Proper billing of bilateral procedures ensures correct reimbursement and eliminates the need for refund requests and payment adjustments. Modifier -RT and -LT Clarification: Modifiers -RT and -LT are informational modifiers only and should not be used when modifier -50 applies. Modifier -50 should be used to report bilateral procedures that are performed on both sides at the same operative session as a single line item. Blue Cross billing requirements for modifier 50 are in accordance with the Centers for Medicare & Medicaid Services. Orthodontia Work in Progress Blue Cross will honor claims for monthly adjustment visits for orthodontia work in progress up to the orthodontic maximum specified in the member s contract. Orthodontists may file claims either monthly or quarterly. CPT only copyright 2010 American Medical Association. All rights reserved. 12

14 Nitrous Oxide Blue Cross includes nitrous oxide charges with other dental services rendered and does not reimburse these charges separately. This applies to all CDT codes. Alternative Dental Procedure Payment Responsibility Form The Alternative Dental Procedure Payment Responsibility Form included in this manual should be used when a member chooses an alternative, non-covered treatment. The form is completed by the dentist and signed by the member, and the member agrees that he/she will be responsible for the difference between the allowed amount of the covered service and the amount charged by the dentist for the chosen alternative procedure in addition to any applicable member cost-sharing amount. The form should be attached to the dental claim form. If you have any questions about these guidelines, please contact Network Development Representative, Paige Carriere at Paige.Carriere@bcbsla.com or Online Alternative Dental Procedure Payment Responsibility Form Provider u Forms for Providers Hardcopy Alternative Dental Procedure Payment Responsibility Form Copy the form on the next page and submit it as directed. u 13

15 An independent licensee of the Blue Cross and Blue Shield Association. ALTERNATIVE DENTAL PROCEDURE PAYMENT RESPONSIBILITY FORM Pursuant to Louisiana Senate Bill 73, which amended and/or reenacted La. R.S. 22:1513(C)(2)(b); 22:250.43(C) and 22:250.48, a Blue Cross and Blue Shield of Louisiana (BCBSLA) member may choose any type, form, or quality of dental procedure, for which insurance coverage is not available, as long as the member approves in advance and in writing the charges for which he/she will be responsible. Additionally, if a member receives a dental diagnosis from a contracted provider that qualifies for a covered service pursuant to the member s contract/certificate or dental contract, the member may: 1. Choose the covered service provided for in the member contract/certificate or dental contract for the treatment of the condition diagnosed; or 2. Choose an alternate type, form, or quality of dental procedure of equal or greater price to treat the diagnosed condition. If the member chooses this option, he/she must agree in advance and in writing to pay the difference between the allowed amount of the covered service and the amount of the chosen alternative service or procedure. Key Dentists should attach this form to the dental claim form when a member chooses an alternative, non-covered treatment. Dentist Information Dentist Name Contact Name National Provider Identifier (NPI) Phone Number Fax Number Covered Service CDT Code Description Additional CDT Code Description Alternative Treatment/Service CDT Code Description Additional CDT Code Description Member Information By receiving the above alternative treatment/service, I agree that I will be responsible for the difference between the allowed amount paid by BCBSLA and the amount charged by the dentist for the chosen alternative service or procedure. Member Signature Date Member Name (please print) Contract Number 18NW1061 R06/08 Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company 14

16 Section 3 CLAIMS SUBMISSION How to File Dental Insurance Claims As a Key Dentist, you agree to submit claims for Blue Cross members on the ADA Dental Claim Form. Blue Cross accepts dental claims hard copy (paper claims) and electronically. It is extremely important that you complete all applicable information in full to facilitate prompt and accurate reimbursement. An example of the ADA Dental Claim Form and instructions on its completion is included in this manual. Using CDT Codes Blue Cross uses CDT, a systematic listing and coding of procedures and services performed by dentists, for processing claims. Each procedure or service is identified with a five-digit code. By using these procedure codes, a dentist can enhance the speed and accuracy of claims payments. PLEASE INCLUDE THE VALID, CURRENT CDT CODE(S) WHEN FILING A CLAIM. Blue Cross cannot accept unspecified codes. Please use the current CDT code that most closely matches the description of the service rendered. Important Note: If CPT codes are used for a non-surgical procedure, the CPT codes will be rejected and returned for the proper CDT code. Also, when using code D9630, Other drugs and/or medicaments, by report, please indicate the name of the medication in the Description area. Please ensure that your office is using the most current edition of CDT codes. To obtain a current book of CDT codes, order online at call , or write to: American Dental Association; Catalog Sales Department; P. O. Box 776; St. Charles, IL National Provider Identifier (NPI) The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires the adoption of a standard unique identifier for healthcare providers. The Centers for Medicare and Medicaid Services (CMS) has assigned national provider identifiers (NPIs) to comply with this requirement. NPIs are issued by the National Plan and Provider Enumeration System (NPPES). This one unique number is to be used when filing claims with Blue Cross as well as with federal and state agencies, thus eliminating the need for you to use different identification numbers for each agency or health plan. To comply with the legislation mentioned above, all covered entities must use their NPI when filing claims. The Blue Crossassigned provider number (individual Social Security Number with a suffix) is no longer used for internal claims processing and reporting. All providers who apply for Blue Cross provider credentialing or who are undergoing recredentialing, regardless of network participation, must include their NPI(s) on their application. Claims processing cannot be guaranteed unless you notify Blue Cross of your NPI(s) prior to filing claims using your NPI(s). Notifying Blue Cross of your NPI Once you have been assigned an NPI, please notify us as soon as possible. To do so, you may use one of the following ways: 1) Include it on your Louisiana Standardized Credentialing Application (LSCA), Health Delivery Organization (HDO) Application or Blue Cross recredentialing application. 2) Include it on the online Provider Update Form at under Provider, Forms for Providers. 3) Submit it along with your name and tax-id or social security number printed on your office letterhead by fax to or by mail to Blue Cross and Blue Shield of Louisiana; Attn. Network Administration; PO Box 98029; Baton Rouge, LA Filing Claims with NPIs Your NPI is used for claims processing and internal reporting. Claim payments are reported to the Internal Revenue Service (IRS) using your tax identification number (TIN). To appropriately indicate your NPI and TIN on UB-04 and CMS 1500 claim forms, follow the corresponding instructions for each form included in this manual. Remember, claims processing cannot be guaranteed if you have not notified Blue Cross of your NPI, by using one of the methods above, prior to filing claims. See the first part of this section for more details on how to submit claims to Blue Cross. CPT only copyright 2010 American Medical Association. All rights reserved. 15

17 For more information, including whom should apply for an NPI and how to obtain your NPI, visit our website or CMS site at If you have any questions about the NPI relating to your Blue Cross participation, please contact us at , option 3. Referring Physician NPIs Referring physician NPIs are required on all applicable claims filed with Blue Cross and HMOLA. For more information on NPIs, visit under Provider, NPI. Transitioning to NPI Only on Claims By mid-2010, Blue Cross will require an NPI on all claims, both electronic and paper; regardless of the provider s network participation. Providers will receive a 30-day notice before we transition to accepting NPI only on claims. Once the transition is made to NPI only, claims received without an NPI, or with an NPI that is not on our records, will be rejected. Claims Mailing Addresses Please mail all completed claim forms to the following addresses for processing: Key Dental Claims FEP Dental Claims, Blue Cross and Blue Shield of Louisiana, BCBSLA FEP Dental Claims P. O. Box P. O. Box Baton Rouge, LA Baton Rouge, LA Out-of-State Claims Refer to the member s ID card. Tips for Submitting BlueCard (Out-of-State) Claims Dental Providers and Oral Surgeons must verify benefits of BlueCard Program members prior to performing services. To do this, call the number on the member s ID card. ADA Claim Form Dental Providers and Oral Surgeons filing claims for dental services on an ADA form (hardcopy) should submit the claim to the Blue Plan named on the member s ID card; do not file with Blue Cross and Blue Shield of Louisiana (BCBSLA). Dental Providers and Oral Surgeons calling for claim status regarding dental services filed on an ADA form should call the number provided on the BlueCard member s ID card; do not call BCBSLA. ADA claim forms received by BCBSLA for dental services for BlueCard members will be sent back to the provider advising the provider to file the claim to the Blue Plan named on the BlueCard member s ID card. Dental claims submitted on an ADA must be processed through the Blue Plan on the member s ID card. Providers should not expect payment from BCBSLA. The member or provider will get paid directly from the BlueCard member s home plan or intermediary adjudicating the claim. Providers should call the number provided on the BlueCard member s ID card for inquiries regarding claim status for dental services filed on an ADA form to the Blue Plan on the member s ID card. CMS-1500 and Electronic Claim Forms Electronic claims received by BCBSLA for dental services provided to BlueCard members will be returned to the provider to re-file the claim to the Blue Plan named on the member s ID card. It is recommended by BlueCard that Dental Providers and Oral Surgeons filing dental services that fall under the medical care category do so on a CMS-1500 (professional) claim form or submit electronically. Dental Services that fall under the medical care category and are filed on a on a CMS-1500 claim form or professional electronic claim form will be processed by BCBSLA and sent to the Blue Plan named on the BlueCard member s ID card for adjudication under medical policy guidelines. This does not guarantee payment. Dental Services filed incorrectly or with missing information on a CMS-1500 claim form or professional electronic claim form will be returned to the provider for a corrected claim. Dental claims submitted on a CMS-1500 claim form or professional electronic claim form may be processed through BlueCard; therefore, providers should expect the remit or payment to come from BCBSLA, if the claim is processed to pay the provider. If the claim is processed by the member s home plan to pay the BlueCard member, the member will receive payment from the member s home Plan and not from BCBSLA. Providers should call BCBSLA for inquiries regarding claim status for dental services filed on a CMS-1500 claim form or professional electronic claim form. 16

18 Example ADA DENTAL CLAIM FORM 17

19 Description of ADA Dental Claim Form 1 Mark this box if patient is covered by state Medicaid s early and Periodic Screening, Diagnosis and Treatment (EPSDT) program for persons under Enter the number provided by the payer when submitting a claim for services that have been predetermined or preauthorized. 3 Enter the patients primary insurance carrier s information Fill in other coverage informationleave blank if no other coverage. 8 Policy Holder/Subscriber s identification number for additional coverage Enter Subscriber s personal insurance information here. 15 This is the member s identification number assigned by Blue Cross This is the member s or employer group s plan or policy number. May also be known as the Certificate number and employer name. 18 Check indicating the relationship of the patient to the Policyholder/Subscriber Complete only if the patient is not the primary subscriber. (i.e. Self not checked in Field 18) 19 Check FTS if the patient is a dependent and a full-time student; PTS is a part-time student. Otherwise, leave blank. 23 Enter if dentist s office assigns a unique number to identify the patient that is not the same as the subscriber identifier number assigned by the payer. (e.g. chart number) 24 Enter date the procedure was performed. 25 Designate tooth number or letter when the procedure code directly involves a tooth. Use the area of the oral cavity code set from ANSI/ADA/ISO Specification number 3950m, Designation System for Teeth and Areas of the Oral Cavity. 26 Enter applicable ANSI ASC X12 code list qualifier: Use JP when designating teeth using the ADA s Universal/National Tooth Designation System. Use JO when using the ANSI/ADA/ISO Specification No Designate tooth number when the procedure code reported directly involves a tooth. If a range of teeth is being reported, use a hyphen (-) to separate the first and last tooth in the range. Commas are used to separate individual tooth numbers or ranges applicable to the procedure code reported. 28 Designate tooth surface(s) when the procedure code reported directly involves one or more tooth surfaces. Enter up to five of the following codes, without spaces: B=Buccal; D=Distal; F=Facial; L=Lingual; M=Mesial and O=Occlusal. 29 Use the appropriate dental procedure code from the current version of the Code on Dental Procedures and Nomenclature. 30 Description of codes. 31 This is the dentist s full fee for the dental procedure reported. 32 This is used when other fees applicable to dental services provided must be recorded. Such fees include state taxes, where applicable, and other fees imposed by regulatory bodies. 33 This is the total of all fees listed on the claim form. 34 Report missing teeth on each claim submission. 35 Use Remarks space for additional information such as reports for 999 codes or multiple supernumerary teeth. 36 The patient is defined as an individual who has established a professional relationship with a dentist for the delivery of dental healthcare. For matters relating to communication of information and consent, this term includes the patient s parent, caretaker, guardian or other individual as appropriate under state law and the circumstances of the case. 37 Subscriber Signature: This is necessary when the patient/insured and dentist wish to have benefits paid directly to the provider. This is an authorization of payment. It does not create a contractual relationship between the dentist and the payer. 38 Indicate the place of treatment by choosing Provider s Office, Hospital, Extended Care Facility (ECF) (e.g. nursing home) or Other. 39 Fill in the number of each type of enclosures in the appropriate boxes provided. 40 Indicate whether or not the treatment is for Orthodontics purposes. 41 If yes is checked in block number 40, list date appliance was placed. 18

20 42 If yes is checked in block number 40, list how many months of treatment are remaining. 43 If yes is checked in block number 40, indicate whether or not a replacement of prosthesis was done. 44 If yes is checked in block number 43, list date of prior placement. 45 Indicate what the treatment is resulting from, if applicable. 46 List date of accident. 47 Report what state the accident occurred. 48 This is the individual dentist s name or the name of the group practice/corporation responsible for billing and other pertinent information. This may differ from the actual treating dentist s name. This is the information that should appear on any payments or correspondence that will be remitted to the billing dentist. 49 Billing Dentist s National provider identifier (NPI). 50 This refers to the license number of the billing dentist. This may differ from that of the treating dentist that appears in the treating dentist s signature block. 51 The Internal Revenue Service requires that either the SSN or TIN of the billing dentist or dental entity be supplied only if the provider accepts payment directly from the third-party payer. When the payment is being accepted directly, report the: 1) SSN if the dentist is unincorporated; 2) Corporation TIN if the billing dentist is incorporated; or 3) Entity TIN when the billing entity is a group practice or clinic. 52 Billing dentist or dental entity s phone number. 52a Additional Provider ID#. 53 This is the treating, or rendering, dentist s signature and date the claim form was signed. Dentists should be aware that they have ethical and legal obligations to refund fees for services that are paid in advance, but not completed. 54 Treating Dentist s National provider identifier (NPI). 55 Treating dentist s license number. 56 This is the full address, including city, state and zip code, where treatment is performed by the treating (rendering) dentist. 57 Treating dentist or treatment location phone number. 58 Additional Provider ID#. 19

21 Example CMS 1500 CLAIM FORM 1500 HEALTH INSURANCE CLAIM FORM APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05 PICA PICA CARRIER 1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1a. INSURED S I.D. NUMBER (For Program in Item 1) CHAMPUS HEALTH PLAN BLK LUNG (Medicare #) (Medicaid #) (Sponsor s SSN) (Member ID#) (SSN or ID) (SSN) (ID) 2. PATIENT S NAME (Last Name, First Name, Middle Initial) 5. PATIENT S ADDRESS (No., Street) 3. PATIENT S BIRTH DATE SEX MM DD YY M F 6. PATIENT RELATIONSHIP TO INSURED Self Spouse Child Other 4. INSURED S NAME (Last Name, First Name, Middle Initial) 7. INSURED S ADDRESS (No., Street) CITY ZIP CODE TELEPHONE (Include Area Code) ( ) 9. OTHER INSURED S NAME (Last Name, First Name, Middle Initial) a. OTHER INSURED S POLICY OR GROUP NUMBER b. OTHER INSURED S DATE OF BIRTH MM DD YY M c. EMPLOYER S NAME OR SCHOOL NAME d. INSURANCE PLAN NAME OR PROGRAM NAME SEX F STATE 8. PATIENT STATUS Single Married Other Full-Time Part-Time Employed Student Student 10. IS PATIENT S CONDITION RELATED TO: a. EMPLOYMENT? (Current or Previous) b. AUTO ACCIDENT? c. OTHER ACCIDENT? YES NO YES NO YES NO 10d. RESERVED FOR LOCAL USE PLACE (State) READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 12. PATIENT S OR AUTHORIZED PERSON S SIGNATURE I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below. CITY STATE ZIP CODE TELEPHONE (Include Area Code) 11. INSURED S POLICY GROUP OR FECA NUMBER a. INSURED S DATE OF BIRTH MM DD YY b. EMPLOYER S NAME OR SCHOOL NAME d. IS THERE ANOTHER HEALTH BENEFIT PLAN? YES NO ( ) c. INSURANCE PLAN NAME OR PROGRAM NAME SEX M F If yes, return to and complete item 9 a-d. 13. INSURED S OR AUTHORIZED PERSON S SIGNATURE I authorize payment of medical benefits to the undersigned physician or supplier for services described below. PATIENT AND INSURED INFORMATION SIGNED DATE 14. DATE OF CURRENT: MM DD YY 19. RESERVED FOR LOCAL USE ILLNESS (First symptom) OR INJURY (Accident) OR PREGNANCY(LMP) 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a. 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. GIVE FIRST DATE MM DD YY 17b. NPI SIGNED 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM DD YY MM DD YY FROM TO 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM DD YY MM DD YY FROM TO 20. OUTSIDE LAB? $ CHARGES 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3 or 4 to Item 24E by Line) YES NO 22. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. 23. PRIOR AUTHORIZATION NUMBER A. DATE(S) OF SERVICE B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. From To PLACE OF (Explain Unusual Circumstances) DIAGNOSIS MM DD YY MM DD YY SERVICE EMG CPT/HCPCS MODIFIER POINTER 25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT S ACCOUNT NO. 27. ACCEPT ASSIGNMENT? (For govt. claims, see back) 31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS (I certify that the statements on the reverse apply to this bill and are made a part thereof.) YES NO F. G. H. I. J. DAYS EPSDT OR Family ID. RENDERING $ CHARGES UNITS Plan QUAL. PROVIDER ID. # NPI 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE $ $ $ 32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH # NPI NPI NPI NPI NPI ( ) PHYSICIAN OR SUPPLIER INFORMATION NPI a. b. a. b. SIGNED DATE NUCC Instruction Manual available at: APPROVED OMB FORM CMS-1500 (08/05) NPI 20

22 Health Insurance Claim Form (CMS-1500) Explanation Block 1 Block 1a Block 2 Block 3 Block 4 Block 5 Block 6 Block 7 Block 8 Block 9 Block 10 Block 11 Block 12 Block 13 Type(s) of Health Insurance - Indicate coverage applicable to this claim by checking the appropriate block(s). Insured s I.D. Number - Enter the subscriber s Blue Cross and Blue Shield identification number, including their three-character alpha prefix, exactly as it appears on the identification card. Patient s Name - Enter the full name of the individual treated. Patient s Birth Date - Indicate the month, day and year. Sex - Place an X in the appropriate block. Insured s Name - Enter the name from the identification card except when the insured and the patient are the same; then the word same may be entered. Patient s Address - Enter the patient s complete, current mailing address and phone number. Patient s Relationship to Insured - Place an X in the appropriate block. Self - Patient is the subscriber. Spouse - Patient is the subscriber s spouse. Child - Patient is either a child under age 19 or a full-time student who is unmarried and under age 25 (includes stepchildren). Other - Patient is the subscriber s grandchild, adultsponsored dependent or of relationship not covered previously. Insured s Address - Enter the complete address; street, city, state and zip code of the policyholder. If the patient s address and the insured s address are the same, enter same in this field. Patient Status - Check the appropriate block for the patient s marital status and whether employed or a student (single, married, other; employed, full-time student, part-time student). Other Health Insurance Coverage - If the patient has other health insurance, enter the name of the policyholder, name and address of the insurance company and policy number (if known). Is patient s condition related to: a. Employment (current or previous)?; b. Auto Accident?; c. Other Accident?. Check appropriate block if applicable. Not required. Patient s or Authorized Person s Signature - Appropriate signature in this section authorizes the release of any medical or other information necessary to process the claim. Signature or Signature on File and date required. Signature on File indicates that the signature of the patient is contained in the provider s records. Insured s or Authorized Person s Signature - Payment for covered services is made directly to participating providers. However, you have the option of collecting for office services from subscribers who do not have a copayment benefit and having the payments sent to the patients. To receive payment for office services when the copayment benefit is not applicable, Block 13 must be completed. Acceptable language is: a. Signature in block d. Benefits assigned b. Signature on file e. Assigned c. On file f. Pay provider Please Note: Assignment language in other areas of the CMS-1500 claim form or on any attachment is not recognized. If this block is left blank, payment for office services will be sent to the patient. Completion of this block is not necessary for other places of treatment. 21

23 Block 14 Block 15 Block 16 Block 17 Date of Current - Enter the first date of illness, injury or pregnancy filed on claim. Same or Similar Illness or Injury - Indicate appropriate date(s) for previous incidents. Dates Patient Unable to Work in Current Occupation - Enter dates, if applicable. Name of Referring Physician - Enter the referring physician s complete name, if applicable. Block 17a Other ID#. The non-npi ID number of the referring physician, when listed in Block 17. Block 17b NPI Required. Enter the national provider identifier (NPI) for the referring physician, when listed in block 17. Block 18 Block 19 Block 20 Block 21 Block 22 Block 23 Block 24a Block 24b Block 24c For Services Related to Hospitalization - Enter dates of admission to and discharge from hospital. Taxonomy Code required on claim if you are a Diagnostic Radiology Center, Emergency Room Physician Group, or Sleep Medicine provider. Laboratory Work Performed Outside Your Office - Enter, if applicable. Diagnosis or Nature of Illness or Injury - Enter the ICD-9-CM code and/or description of the diagnosis. Not required. Enter the authorization number obtained from Blue Cross/HMOLA, if applicable. Date(s) of Service - Enter the from and to date(s) for service(s) rendered. Place of Service - Enter the appropriate place of service code. Place of service codes are: Inpatient - 21 Outpatient - 22 Office - 11 EMG - Enter the Type of Service code that represents the services rendered. Block 24d Block 24e Block 24f Block 24g Block 24j Procedures, Services, or Supplies - Enter the appropriate CPT or HCPCS code. Please ensure your office is using the most current CPT and HCPCS codes and that you update your codes annually. Append modifiers to the CPT and HCPCS codes, when appropriate. Diagnosis Pointer - Enter the numeric code that corresponds with the diagnosis code in Block 21 when more than one diagnosis is given. Refer to the Procedure and Diagnosis Codes and Guidelines portion of the section on Claims Submission of this manual for more information. Charges - Enter the total charge for each service rendered. You should bill your usual charge to Blue Cross regardless of our allowable charges. Days or Units - Indicate the number of times the procedure was performed, unless the code description accounts for multiple units, or the number of visits the line item charge represents. Rendering Provider ID# - Enter the national provider identifier (NPI) for the rendering physician for each procedure code listed when billing for multiple physicians services on the same claim. Laboratory, Durable Medical Equipment, Emergency Room Physicians, Diagnostic Radiology Center, Laboratory and Diagnostic Services, and Urgent Care Center providers do not have to enter a physician NPI in this block. Please enter the facility NPI in blocks 32a and 33a as instructed. 22