CONFERENCE TOPICS - UB & UB & UB & 1500 PPO

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2 CONFERENCE TOPICS Electronic Claim Submission - UB & 1500 Real-Time Claim Adjudication - UB & 1500 Real-Time Claim Estimation - UB & 1500 PPO Fee Schedule Online Tips and Reminders Questions/Comments 2

3 Electronic Claim Submission Mountain State has determined that paper claims are more costly to process and can ultimately result in payment delays or errors. Beginning January 1, 2010, all commercial and HHIC primary and secondary hospital inpatient and outpatient claim submissions are to occur electronically. Consistent with CMS, MSBCBS is currently granting a grace period through December 31, 2009 allowing hospitals and respective Trading Partners to make any system or process adjustments necessary. After January 1, 2010 hospital claims will be returned when filed via paper. A free electronic solution for both UB & 1500 billers is to submit your claims through the NaviNet Claim/Estimation Submission transaction. The NaviNet Claim Submission transaction can accommodate primary, secondary and tertiary claims as well as local, FEP, BlueCard and HHIC/Freedom Blue claims for our UB & 1500 providers. 3

4 Claim Submission These will vary based on your needs. May only be UB or

5 UB CLAIM SUBMISSION FOR SECONDARY PAYOR For MSBCBS members key the ID# and click on search to auto fill in this screen For BlueCard members, type all required fields 5

6 6 NAIC CODE: For prefixes HQM & HKP (Mt State HHIC) choose For all other members use 54828, including FEP, BlueCard & local members

7 7 Complete all appropriate fields for the services being submitted

8 8 Choose HHIC IF member has a prefix of HQM or HKP.

9 9 Secondary claim example: Charge $ Primary Paid $ Contractual Obligation $40.00 (provider) Patient Responsibility $60.00 (deductible)

10 Mt State is the secondary carrier. Mt State or HHIC must always be one of the payers on this screen This will always default to YES. If you are reporting Other Insurance payments at the line level, keep it as YES. If you are reporting OI information at the claim level, click NO 10

11 11 System will automatically total your charges being submitted.

12 12 Complete all appropriate fields for submission

13 13 Final screen to check your claim before sending

14 14 Bottom of the final screen. When you click Submit from this screen, you send the claim to Mt State BCBS.

15 Claim # is displayed if accepted or adjudicated Submission Status Scenarios Adjudicated/Finalized = Claim successfully submitted & adjudicated by MBSCBS. (Submitted on the same DOS) Accepted = Claim successfully submitted & accepted by MSBCBS. Rejected = Claim has errors displayed in red. Correct and resubmit Sent = Claim submission taking longer than expected. Claim is saved, recheck for status Rarely a formatting error could occur. Will show a status of Sent and a message to contact NaviNet Customer Care for research 15

16 REAL-TIME CLAIMS Any claims submitted via NaviNet is an electronic submission. The submission is in a real-time mode where electronic edits are applied and if no errors are incurred, the claim enters the MSBCBS claim system. Real-Time Claims that are for Mt State members, including HHIC/Freedom Blue prefixes of HQM & HKP, could auto-adjudicate/process if the date of service = the date of submission and the services submitted can process through our claim system without pending for review or processing intervention. This is referred to as Real- Time Adjudication (RTA) The RTA claims would show a Claim Submission result with a status of Adjudicated/Finalized and also return a Real-Time Member Liability Statement (next slide) showing the amount the member owes for the claim. Claims submitted for FEP or BlueCard members cannot be adjudicated in a real-time mode (MSBCBS does not determine their benefits). However they can be submitted electronically via NaviNet like the claim shown on the previous slide. 16

17 Real Time Member Liability Statement for a Real-Time Adjudicated Claim Amount the member owes. This is the members office co-pay 17

18 1500 Submission Mirrors the UB Functionality The format of the 1500 Claim Submission screens are quite similar to the UB Claim Submission screens, while accommodating the necessary 1500 data fields. Simply choose 1500 Submission from the Claim/Estimation transaction. The 1500 Claim Submission screen does not require the NAIC code on the Header page. If the claim is for our HHIC/Freedom Blue members (prefix HQM & HKP) simply choose HHIC as the Primary Payer A on the Payer screen. Secondary 1500 claim submissions are handled the same as the UB claims, capturing the appropriate CAS codes and amounts (PR-patient responsibility, COcontractual obligation) 18

19 Real-Time Claim Estimates

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21 21 Choose NAIC code if prefix = HQM or HKP, otherwise use 54828

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24 24 Final check of services to be estimated. Click Submit

25 Real Time Member Liability Statement for a Real-Time Estimated Claim Shows member responsibility (coinsurance) Shows Member Responsibility (coinsurance) 25

26 CLAIM LOG All NaviNet Claim Submissions and Estimations are stored on the Claim Log. Access the Claim Log through the Claim/Estimation Submission transaction OR through Office Central. Claim Log here too 26

27 NEW CHANGES EFFECTIVE AUGUST 2009 FOR CLAIM SUBMISSIONS AND ESTIMATIONS SAVE TIME Effective August 10, 2009 you can use the claim log to; - Take an existing estimate and send in a new estimate - Take an existing estimate and send it in as a new claim - Take an existing claim and send it in as a new claim Simply recall the estimate or claim from the claim log, make coding changes if appropriate, and then send in the new document. 27

28 ESTIMATES CAN BE CHANGED INTO A CLAIM OR A NEW ESTIMATE FROM THE CLAIM LOG Copy will create a 2 nd estimate. Submit Claim will turn the estimate into a claim 28

29 CLAIMS CAN BE COPIED AS A NEW OR CORRECTED CLAIM FROM THE CLAIM LOG Copy will create another claim. Change fields as needed 29

30 Choosing a Real-Time Workflow The availability of both capabilities allows for several flexible options when implementing Real-Time in your office setting. Here are a few options Submit RTE prior to service based on anticipated services to set patient $ expectations and collect during check-in Submit RTA during check-out based on actual services and collect $ during check-out Submit RTE during check-in based on anticipated services and collect $ during check-in Submit RTE during check-out based on actual services and collect $ during check-out Ideal scenario: Submit estimate prior to service to set patient s financial expectations. During check-out process submit a Real-Time claim and collect member responsibility before the patient leaves the office. 30

31 REAL-TIME POSTER & MEMBER FLIER - Available 31

32 Real-Time Brochure 32

33 PPO FEE SCHEDULE IS ON NAVINET The most current NaviNet PPO Fee Schedule can be found in NaviNet using the Resource Center transaction, then choosing Administrative Reference Materials. Click here to view the Fee Schedule 33

34 34 Scroll down to the bottom and choose the format to view. You can also download either format to your computer

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36 PLEASE MAXIMIZE NAVINET USE Are all the Mountain State Blue Cross Blue Shield/NPI numbers that you use in your provider dropdown boxes? Are there other departments or personnel in your organization that can benefit from using NaviNet? Is there staff at another location that could use the eligibility/benefit transaction or cash management transactions? Do you have a billing company that calls in for claim status inquiries? They can be set up in NaviNet too. If you are a Security Officer, please review your list of NaviNet users to be sure terminated employees have no access and new hires do. Remember NaviNet can be accessed from any computer, even at home! Please keep your files current. Additional training is available through NaviNet Customer Care as well as Mountain State Staff. 36

37 NaviNet Tips and Reminders A sporadic problem with the Blue Exchange Eligibility & Benefit transaction has been identified and was escalated for resolution. NaviNet is returning a message of No Medical Coverage when the member did have benefits. The Interqual survey ( mentioned at last years workshop) for facility Urgent Care Admissions Authorization Submissions has not been turned on at this time. We anticipate using this functionality in the near future. In addition to searching for a claim status inquiry by claim number only, you can now also check an authorization by the authorization number only. Use the Referral/Auth Inquiry transaction and enter the authorization number only (no ID number or Date of Service needed) Remember NaviNet is available Monday through Saturday from 5:00 a.m until 3:00 a.m. and on Sunday from 5:00 a.m. until 5:00 p.m. For General questions & training on using NaviNet transactions, please contact NaviNet Customer Care at Monday-Friday from 8a.m. to 11p.m & Saturday from 8a.m. to 3p.m. For detailed training of transactions please contact your External Provider Relations Representative or me, (Michelle Beihl ). Please stop by the NaviNet vendor table to request additional training or needs. They can do a demo to show you additional transactions. 37

38 QUESTIONS OR COMMENTS Thank you! Michelle Beihl NaviNet Coordinator