Friday, April 1, 2011

Using BCBS clear claim connection

Clear Claim Connection

You can simulate the likely procedure code editing rules for your BCBSF claims prior to submission or
after receiving the remittance advice by using Clear Claim Connection; available through the Availity
Health Information Network.

This tool is intended for use as a simulation for general information and is not binding on BCBSF. Medical
Coverage Guidelines, member benefits, terms, limitations and exclusions will override any prepayment
edit.
Claims are adjudicated using the claim processing rules for procedure code editing in effect at the time
the claim is submitted. Procedure code edits are typically updated twice per year. Clear Claim Connection
only returns current claim editing logic. Therefore, if your simulation results do not match how your claim
processed, it is possible a version update may be the reason.
Claim editing rules are consistent for most BCBSF claims. Medicare Supplement and Medicare
Advantage Private Fee-for-Service claims are not subject to the procedure code editing rules displayed
by Clear Claim Connection.
How to Use Clear Claim Connection
From Availity’s home page, under the Claims Management Menu tab, click on Research Procedure Code
Edits. Next, you must accept the Terms and Conditions of Use. On the Claim Entry screen, provide the
data listed below and click on the Review Claim Audit Results button. The information returned is
confidential and solely for the use of authorized provider practices.
• Patient’s gender
• Patient’s date of birth
• Procedure code
• Modifiers, if applicable (optional data field)
• Date of service (needed to determine active and non-active procedure codes)

This capability also provides source information and clinical rationale for editing rules, but only on
procedure lines with a “Disallow” or “Review” response in the Recommended data field. To view this
additional information, click on the line to highlight it, then click the Review Clinical Edit Clarification
button. Or, just double click the line to review the related clinical edit clarification.

Note: Use of Clear Claim Connection requires Internet Explorer 5.5 SP1 or higher. For those using a popup
block, this may need to be disabled to view the site.

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