Complete claim submission - some tips

INTRODUCTION AND GENERAL CLAIMS GUIDELINES

We need your help to achieve BCBSTX’s goal of accurate and efficient claims payment. Share the following guidelines with your staff and, if applicable, with your billing service agent and electronic data processing service agent. It is important that everyone involved understands the guidelines for preparing and submitting claims for services rendered to BCBSTX Members.

THE IMPORTANCE OF A CLEAN CLAIM

This section will help you understand how to submit a claim to BCBSTX correctly the first time, which will help avoid delays in processing.
Claims submitted correctly the first time are called “clean”. That means that all required fields have been completed in accordance with Health Insurance Portability and Accountability Act of 1996 (HIPAA) requirements. It also means that the correct form was used for the type of service provided.

We return claims submitted with incomplete or invalid information, and request the claim be corrected and resubmitted. If using a clearinghouse for Electronic Data Interchange (EDI), the clearinghouse/gateway also rejects claims that are incomplete or invalid. You are responsible for working with your EDI vendor to help ensure that claims that “error out” from the EDI gateway are corrected and resubmitted.


Claim Forms

Generally, there are two types of forms used for submitting claims for reimbursement. They are:

1.   The CMS-1500 for professional services (refer to the CMS-1500 Claim Form section)
2.   The CMS-1450 (UB-04) for institutional services (refer to the CMS-1450 (UB-04) Claim Form section)

These forms are available in both electronic and hard copy/paper format.
Information on how to complete each of these forms is available later in this Manual. Click on the appropriate form name in the Claim Forms and Filing Limits table below to link to a sample image of that form followed by a general instructions on how to complete its more important fields.

Claim Filing Limits

All claims must be submitted within the contracted filing limit to be considered for payment. We will deny claims that are received past the filing limit. See the Submitting a Claim section for standard claim filing and processing time frames. Submit claims as soon as possible following delivery of service to avoid delays in processing.

BCBSTX is not responsible for a claim never received. Prolonged periods before resubmission may cause you to miss the filing limit. Determine filing limits as follows:

If BCBSTX is the primary payer, you have a specific length of time between the last date of service on the claim and the BCBSTX receipt date.

If BCBSTX is secondary payer, you have a specific length of time between the other payer’s Remittance Advice (RA) date and the BCBSTX receipt date.


CLAIM FORMS AND FILING LIMITS

Form : CMS-1500 Claim Form

Type of Service to be Billed : Physician and other professional services: Specific ancillary services including physical and occupational therapy, skilled nursing facility (SNF), and speech Ancillary Services including: Audiologists, ambulance, ambulatory surgical center, dialysis, durable medical equipment (DME), diagnostic imaging centers, hearing aid dispensers, home infusion, hospice, laboratories, prosthetics and orthotics, and free standing SNFs. Some Ancillary Providers may use a CMS-1450 (UB-04) if they are ancillary Institutional Providers. Ancillary charges by a hospital are considered facility charges.

CMS-1450 (UB-04) Claim Form : Hospitals, Institutions, Home Health Services and Ancillary Providers
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SUBMITTING A CLAIM

Methods for Submitting Claims

There are two methods for submitting a claim:
1.   Electronic Data Interchange (EDI) (preferred)
2.   Paper or hard copy

Electronic Claims

Completion of electronic claims can speed claim processing and prevent delays.

Submit claims electronically through a plan-approved electronic billing system software vendor and/or clearinghouse.

If you use EDI, you must include the following Provider information: Provider name Rendering Provider NPI

Group NPI

The Federal Provider Tax Identification (ID) number
BCBSTX’s Payer Identification (ID) number 84980
National Provider Identifier (NPI)

BCBSTX cannot be responsible for claims never received. You must work with your vendors to help ensure files are successfully submitted to BCBSTX. Failure of a third party to submit a claim to BCBSTX may risk your claim being denied for untimely filing if those claims are not successfully submitted during the filing limit.

After submitting electronic claims, do the following:

Monitor claim status on the Provider website or through Interactive Voice Response (IVR). Please note that the IVR accepts either your billing National Provider Identifier (NPI) or your Federal Tax Identification Number (TIN) for Provider identification. Should the system not accept your billing NPI or Federal TIN, the system will route your call to a Customer Care Center representative who will help you with your query. For purposes of assisting you, we may ask you for your TIN.

Watch for (and confirm) plan Batch Status Reports from your vendor/clearinghouse to help ensure your claims have been accepted by BCBSTX.

You can correct and resubmit Batch Status Reports and error reports electronically.

Correct any errors and resubmit (electronically) immediately to prevent denials due to untimely filing.

A front-end edit process may occur with your contracted vendor and/or clearinghouse. If claims are not in HIPAA-compliant transaction code set, the claim may be “errored out” by your EDI vendor or clearinghouse. An error report will be sent to you and your claim will never reach BCBSTX’s EDI gateway. You will need to review these reports and file again.



Paper Claims

For dates of service beginning April 1, 2012 and beyond, only the 5010 format will be accepted.
Paper claims are scanned for clean and clear recording of data. To get the best results, paper claims must be legible and submitted in the proper format. Follow these paper claim submission requirements to speed processing and prevent delays:

Use the correct form and be sure the form meets Centers for Medicare and Medicaid Services standards
Use black or blue ink; do not use red ink, as the scanner may not be able to read it
Use the “remarks” field for messages
Do not stamp or write over boxes on the claim form

Send the original claim form to BCBSTX, and retain the copy for your records Do not staple original claims together; BCBSTX will consider the second claim as an attachment and not an original claim to be processed separately

Type information within the designated field. Be sure the type falls completely within the text space and is properly aligned with corresponding information. If using a dot matrix printer, do not use “draft mode” since the characters generally do not have enough distinction and clarity for the optical character reader to accurately read the contents.

When submitting paper claims, the following Provider information must be included: Provider name Rendering Provider Group or Billing Provider

The federal Provider Tax Identification (ID) number

National Provider Identifier (NPI) Medicare number (if applicable)

Attachments to Paper Claims

Some claims may require additional attachments. Be sure to include all supporting documentation when submitting your claim.


CLINICAL SUBMISSIONS CATEGORIES

The following is a list of claims categories where we may routinely require submission of clinical information before or after payment of a claim:

    Claims involving precertification/prior authorization/predetermination (or some other form of utilization review) including but not limited to:

Claims pending for lack of precertification or prior authorization

Claims involving medical necessity or experimental/investigative determinations Claims involving drugs administered in a physician’s office requiring prior authorization Claims requiring certain modifiers

Claims involving unlisted codes

Claims for which we cannot determine from the face of the claim whether it involves a covered service; thus, the benefit determination cannot be made without reviewing medical records (including but not limited to emergency service-prudent layperson reviews and specific benefit exclusions). A prudent layperson is someone who possesses an average knowledge of health and medicine.

Claims that we have reason to believe involve inappropriate (including fraudulent) billing Claims that are the subject of an audit (internal or external), including high-dollar claims Claims for individuals involved in case management or disease management

Claims that have been appealed (or that are otherwise the subject of a dispute, including claims being mediated, arbitrated or litigated)

Other situations in which clinical information might routinely be requested: Accreditation activities
Quality improvement/assurance activities

Credentialing Coordination of benefits Recovery/subrogation

Examples provided in each category are for illustrative purposes only and are not meant to represent a complete list within the category.

NATIONAL PROVIDER IDENTIFIER

The National Provider Identifier (NPI) is a 10-digit number. NPIs are issued only to Providers of medical and health services and supplies. NPI is one provision of the Administrative Simplification portion of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). NPI is intended to improve the efficiency of the healthcare system and reduce fraud and abuse.

There are several advantages to using your NPI for claims and billing. NPI offers Providers the opportunity to bill with only one number. Some of the advantages for plan Providers using NPI include the following:

The billing process is simplified, as it is no longer necessary to maintain and use legacy identifiers for each of the plans.
Administering changes for addresses and locations is easy.

Providers will only have one number for electronically transacting business with any health plan with which they are affiliated.

Providers may apply for an NPI individually online at the National Plan and Provider Enumeration System (NPPES) website at www.nppes.cms.hhs.gov or by obtaining a paper application by calling the NPPES number at 800-465-3203.

Unattested NPIs

BCBSTX will deny claims with an unattested NPI, even if you provide legacy information. Attestation is the process of registering and reporting your NPI with your state Medicaid agency. Providers serving Texas Medicaid (STAR) patients are required to register and attest their NPI with the state of Texas Medicaid & Healthcare Partnership (TMHP). You can attest (register and report) your NPI with Texas Medicaid and Healthcare Partnership (TMHP) at www.tmhp.com. Attesting makes processing and paying your claims more efficient and accurate. During attestation, you also may be assigned a benefit code to identif  specific state programs as part of NPI-related data. You can verify your NPI assignment at the National Plan and Provider Enumeration System (NPPES) website at www.nppes.cms.hhs.gov.

The Centers for Medicare and Medicaid Services (CMS) has developed regulations for a batch enumeration called Electronic File Interchange, or EFI. The EFI process will be available to large Provider groups such as hospitals and Provider practice groups. More information on EFI can be found at www.nppes.cms.hhs.gov.

Although a Provider may not be currently billing to Medicaid or other publicly funded programs, a participating Provider must still apply for an NPI with CMS. According to the NPI Final Rule, BCBSTX requires the NPI on paper claims for our participating Providers.

Online Resources for NPI Information

The following websites offer additional NPI information: Centers for Medicare and Medicaid Services: www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative-

Simplification/NationalProvIdentStand/index.html

Q: Where do I indicate referring or ordering provider’s information on my claim?

A: Indicate the referring or ordering provider’s information in the section titled Name of referring provider or other source (Item 17 & 17b of the CMS-1500 paper claim form or the 2310A Referring Provider Loop, segments NM101 using qualifier DN or DK, NM103-NM105 [Name], NM108 using [XX] qualifier, and NM109 [NPI] of the 837P electronic claim) as indicated below.

• Report the name of the referring or ordering practitioner of a service in Item 17 (837P 2310A loop, segment NM1) and the appropriate qualifier to the left of the dotted line on the CMS-1500 (02/12) claim form: DN (referring provider) or DK (ordering provider)

• No information should appear in Item 17a (837P 2310A loop, segment REF02). Item 17a was formerly used to report the Unique Physician Identification Number (UPIN), which is no longer used -- leave this item blank. Information appearing in this item or loop will cause your claims to be returned as unprocessable and rejected electronically.

• Report the National Provider Identifier (NPI) of the referring/ordering provider in Item 17b or the 837P 2310A Referring Provider Loop, segments NM101 using qualifier DN (referring provider) or DK (ordering provider), NM103-NM105 [Name], NM108 using [XX] qualifier and NM109 [NPI].

• Note: When a service is referred or ordered by another practitioner, a valid NPI is required and must be reported. Your claims will be returned as unprocessable if the NPI is required and is missing, invalid or submitted in the wrong item (e.g., a valid NPI submitted in Item 17a).


Q: Where do I enter the place of service (POS) code on my claim?

A: The POS code should be entered in the 2400 Place of Service Code loop (segment SV105) of the 837P electronic claim (Item 24B on the CMS-1500 paper claim form).
It is important to ensure you bill the appropriate POS code on all claims to avoid potential overpayments. It is recommended you review your claims and systems for proper billing of the place of service codes.

• If you use an outside billing agency or clearinghouse, make sure they are billing all of your claims with the correct place of service code. It is your responsibility to ensure your claims are billed correctly.


Q: Where do I indicate a rendering physician’s billing number on my claim?

A: If the practitioner rendering the service is part of a billing group, report the individual practitioner’s National Provider Identifier (NPI) in the Rendering Physician # area (2310B loop, segments NM108 [XX] and NM109 [NPI], of the 837P electronic claim or Item 24J of the CMS-1500 paper claim form).

• NPI is required for all rendering providers. If the NPI is missing, invalid, or submitted in the wrong area (e.g., valid NPI submitted in the upper, shaded portion of Item 24J), your claims will be returned as unprocessable.

• Note: If submitting claims on the CMS-1500 paper claim form, report the NPI of the individual practitioner in the lower, non-shaded portion of Item 24J. Place no information in the upper, shaded portion of Item 24J or your claim will be returned to you as unprocessable.

If the rendering provider is an independent lab, ambulatory surgical center (ASC), independent diagnostic testing facility (IDTF), ambulance supplier, or a solo practitioner not associated with a billing group, a rendering provider identifier is not required in the Rendering Physician # area. Report the NPI of these types of providers in the 837P 2010AA Billing Provider loop, segments NM 108 (XX) and NM109 (NPI) of the electronic claim or Item 33a of the paper claim form.

Q: I purchased a portion of a diagnostic test. When I complete the claim, where and how do I indicate this information?
A: If you purchased the technical component (TC) or interpretation (PC) of certain diagnostic tests from a separate entity that does not share a practice location with the billing provider, submit a separate claim for the anti-markup (purchased) service.

Claims for anti-markup services should be completed in the same manner as a standard claim. Below are instructions for areas of particular attention when completing anti-markup service claims.
Paper claim instructions

1. If submitting an anti-markup service on a CMS-1500 paper claim form, mark "Yes" in Item 20 and enter the purchase amount and indicate the national provider identifier (NPI) of the performing entity in Item 19.
• Note: Claims will be returned as unprocessable if:
• Item 20 has "Yes" marked with no dollar amount.
• Item 20 has "No" marked with a dollar amount.
• Item 20 has a dollar amount, but "Yes/No" is not marked.

2. Enter the name and address of the location where the service was physically rendered in the Service Facility Location Information area (paper claim form Item 32) and indicate the NPI of the performing entity who actually rendered the service in the Service Facility Location ID area (Item 32a of the paper form).

• Reminder for paper claim submitters: Only one address can be billed per claim; do not include the PC on a claim with a purchased TC or vice versa. Failure to submit a separate paper claim for each component will result in your claim being returned as unprocessable.
Electronic claim instructions

1. Complete the 837P 2400 loop (Purchased service information), segments PS101 [Purchased service provider identifier] indicating the NPI of the entity who actually rendered the service and PS102 [Purchased service charge amount] indicating the amount you paid to the performing entity for the service.

• Example: PS1*1234567890*57.35

2. Complete the 837P 2310D loop with the name and address of the entity's location where the purchased service was physically rendered as it would typically be completed. Indicate the NPI of the provider from whom the services were purchased in the Service facility location ID area (2310D Facility Primary Identifier loop, segments NM108 [XX] and NM109 [NPI].

3. Additionally, complete the Purchased Service Provider Information area by entering the entity's information from whom the services were purchased in the 837P 2420B loop, segments NM101, NM102, NM108, NM109, for all anti-markup services.
• NM101 = Entity identifier code (enter 'QB' in this field)
• NM102 = Entity type qualifier (person='1'; non-person/facility='2')
• NM108 = Identification code qualifier (XX)
• NM109 = Purchased service provider identifier (NPI)

Refer to the Reporting service facility location information FAQ on the First Coast provider website for additional completion details.

Points to remember for all anti-markup services: An NPI is required on all anti-markup service claims.

• Do not complete Item 32b (electronic loop 2310D, segment REF02). If any information is entered, your claim will be rejected or returned as unprocessable.
• If an NPI is missing, invalid, or submitted in the wrong area (e.g., valid NPI submitted in Item 32b or electronic loop 2310D, segment REF02), the claim will be returned as unprocessable.
• Note: Effective on or after April 1, 2015, billing physicians and suppliers are required to report the name, address, ZIP code, and NPI of the performing physician or supplier when the performing physician or supplier is enrolled in a different contractor’s jurisdiction. Physicians and other suppliers will no longer be permitted to submit their own NPI in Item 32a (or its electronic equivalent) when the performing physician or supplier is located in another jurisdiction.

• Example 1 (Puerto Rico): If a San Juan provider purchases a service performed by a provider in San Sebastian, the San Sebastian provider's address and NPI should be reported.

• Example 2 (Florida): If a Jacksonville, Florida provider purchases a diagnostic service from a mobile provider located in Kingsland, Georgia, they would report the physical location and NPI of the provider where services were performed (Kingsland, GA).


Q: What do I report in Item 32 (service facility location information) of the CMS-1500 paper claim form?

A: For services payable under the Medicare Physician Fee Schedule (MPFS) and anesthesia services, report the name and complete address (including ZIP code) of the physical location where services were rendered in Item 32. This information needs to be completed for all paper claims submitted to Medicare. Report a nine-digit ZIP code (instead of five digits) if the physical location is in an affected locality

The service facility location ID (Item 32a of the paper claim form) is only used for the National Provider Identifier (NPI) of providers who render a purchased service. For details pertaining to purchased diagnostic tests, please refer to the Indicating the TC of a diagnostic service FAQ on the FCSO provider website.

• Note: No information should be entered in Item 32b of the paper claim, as it is no longer used. Claims will be returned as unprocessable if any information appears in Item 32b.

Q: Where do I indicate my billing entity’s provider number on my claim?
A: The billing entity’s National Provider Identifier (NPI) should be reported in the 2010AA Billing Provider Loop of the 837P electronic claim or Item 33a of the CMS-1500 paper claim form.

Important note: The NPI of the billing provider is required on all claims. Paper claims will be returned as unprocessable and electronic claims may be rejected if:
• Any information appears to be missing or invalid in the 837P 2010AA loop, REF02. Item 33b of the paper form should be left blank.
• The billing provider’s NPI is missing, invalid, or is located in the wrong area (e.g., valid NPI submitted in Item 33b.)

Reminder: When billing services rendered by an individual associated with an incorporated entity or a group, the individual practitioner’s NPI must be reported in the Rendering Physician’s area (the 2310B Rendering Provider Loop of the 837P electronic claim or Item 24J of the paper claim form) and the billing entity or group identifier would be reported as indicated above. If billing services for an independent lab, ambulatory surgical center (ASC), independent diagnostic testing facility (IDTF), ambulance supplier, or solo practitioner not associated with a group, a rendering provider identifier in Item 24J or loop 2310B is not required.


When not to show patient paid amounts on claims

Some providers who accept assignment have a concern that Medicare issues partial checks to beneficiaries. Such checks are generally issued because of a patient paid amount in item 29 of the CMS-1500 (02/12) claim form. Here are a few notes concerning this situation:

• When assignment is accepted, Medicare Part B recommends:
• Since it is difficult to predict when deductible/coinsurance amounts will be applicable (and over-collection is considered program abuse), it is recommended that providers do not collect these amounts until Medicare Part B payment is received.

• If you believe you can accurately predict the coinsurance amount and wish to collect it before Medicare Part B payment is received, note the amount collected for coinsurance on your claim form. It is recommended that providers do not collect the deductible prior to receiving payment from Medicare Part B because, as noted above, over-collection is considered program abuse. In addition, this practice can cause a portion of the provider's check to be issued to beneficiaries on assigned claims.

• Do not show any amounts collected from patients if the service is never covered by Medicare Part B or you believe, in a particular case, the service will be denied payment. Where patient paid amounts are shown for services that are denied payment, a portion of the provider's check may go to the beneficiary.

• There is no need to show a patient paid amount in item 29 of form CMS-1500 (or electronic equivalent) when assignment is not accepted.