Blue Cross and Blue Shield of Illinois. An Independent Licensee of the Blue Cross and Blue Shield Association

Transcription

1 Blue Cross and Blue Shield of Illinois An Independent Licensee of the Blue Cross and Blue Shield Association Shared Claims Processing Implementation Manual

2 S H A R E D C L A I M S P R O C E S S I N G Implementation Manual Blue Cross and Blue Shield of Illinois 300 East Randolph Street Chicago, IL NOTICE: This material is the property of Blue Cross and Blue Shield of Illinois. Pursuant to the Inter-Plan Teleprocessing Services License agreement, the Consent and Confidentiality Agreement, and the Consent to Removal Agreement, this material is to be treated as confidential.

3 TABLE OF CONTENTS Chapter 1 1 Introduction 1 About Shared Claims Processing 2 Exchange of Claim Data 2 Open Communication 3 Chapter 2 4 Implementing the Process 4 Initial Evaluation 5 Planning 5 Connectivity Information 6 Membership 6 ID Cards 8 Transmission and Disposition File Layouts 8 Implementation and Testing 9 Downloading Electronic Files 10 Production 10 Provider Communication 11 Member Communication 11 Chapter 3 12 Claims Pre-Adjudication 12 BCBSIL Claims Pre-Adjudication 13 Account Claims Pre-Adjudication 26 Requests for Additional Information 27 Chapter 4 29 Illinois Claims Adjudication 29 Application of Pricing Data 29 Claims Balancing 31 COB Processing 32 Pended Claims 33 Illinois Adjustments 33 Adjustment Types 34 Chapter 5 40 BlueCard Claims Adjudication 40 HPA Claims Processing 41 ALIM Claims Processing 41 Adjustments (BlueCard) 42 BlueCard Disposition Requirements 42 Chapter 6 44 Claims Post-Adjudication 44 Disposition File Format Validation 44 Claim Rejection 45 Payment to Providers 46 Issuance of Provider Claim Summaries 46 Payment to Members 46 Explanation of Benefits 47 Reporting and Billing 47 BARS Report 48 BlueGateway Report 48 Backlog Report 48 Chapter 7 49 Timely Claims Processing 49 State Prompt Payment 49 Contractual Prompt Payment 50 Department of Labor Informational Files 51 Incentive Reports 51 Chapter 8 53 Systems Support and Availability 53 BCBSIL Mainframe 53 Axway 54 BCBSIL Help Desk 54

4 Chapter 1 Introduction S hared Claims Processing (SCP) was developed as a means to allow self-administered accounts to access the extensive Blue Cross and Blue Shield (BCBS) PPO network. As a member of Blue Cross and Blue Shield of Illinois (BCBSIL), members have nationwide access to contracting providers in the PPO networks linked through the BlueCard PPO Program when employees or their covered dependents live, work or travel anywhere in the country. The national PPO network includes more than 92 percent of all physicians and 96 percent of all hospitals in the country. The BCBSIL network is the largest in Illinois, with more than 33,000 contracting physicians and specialists and over 200 contracting hospitals. As one of the largest health insurers in the country and the largest health insurer in Illinois, BCBS is able to contract for savings or negotiate lower costs with physicians and hospitals. In exchange for a steady volume of patients, network doctors and hospitals agree to provide their services at a discounted fee. 1

5 About Shared Claims Processing Shared Claims Processing has been designed to allow accounts to retain control of benefit determination, membership data and claim processing methods. The goal of Shared Claims Processing is to meet these requirements in the most durable, flexible and cost-effective manner possible. There are two Shared Claims Processing options available to clients which are made up of multiple components. 1. BlueCard Screen (HPA)/Illinois Process 2. BlueCard Automation (ALIM/HPA)/Illinois Process Each of these options has technical and processing requirements which will be discussed in detail in subsequent chapters. Regardless of which option a client chooses, the account and BCBS maintain contact with members and providers respectively. Accounts should continue to correspond with members, answer claim inquiries, maintain eligibility, make payments to the members, issue Explanation of Benefits (EOB) information, retain accumulator information and collect Coordination of Benefit (COB) information. They should also stop sending out Provider Claim Summaries (PCS) and 1099 s for BCBS paid providers. BCBS will communicate with contracted providers. This arrangement allows BCBS to enforce established contracts with providers to receive discounts. BCBS will pay its providers as well as answer their claim status inquiries and respond to electronic inquiries for eligibility and benefit information. Note: Accounts may not seek to establish independent discount arrangements with BCBS hospitals and ancillary providers. This includes PPO and non-ppo hospitals, as well as ancillary providers that have a discount contract with BCBS. Exchange of Claim Data All medical claims should be received by BCBS since most providers will electronically submit their claims directly to BCBS. Claims data will be sent to the account via the Transmission File. Once the account has adjudicated the 2

6 claims, they will be returned to BCBSIL via a Disposition Record. Details of this process will be reviewed throughout this manual. Open Communication The key to fully understanding the process and the responsibilities of both the account and BCBSIL is to keep communication lines open. Extensively testing the claims transmission and disposition process will reveal areas that need to be addressed by the Implementation Team (see Chapter 2 Implementing the Process for a list of team members). Once in production, it is still crucial to continue communicating questions or concerns to ensure quality claims processing is maintained. 3

7 Chapter 2 Implementing the Process O nce an account has made the decision to move forward with Shared Claims Processing, an implementation date will be established and an Implementation Team from BCBSIL will assist and guide the account through the entire three- to six-month process. The Implementation Team will consist primarily of three key individuals: Account Executive: Responsible primarily for financial questions, contractual issues, individual member requests and various production concerns. Marketing Support representative (aka, Implementer): Main point of contact during the implementation as well as systems related issues during production. Full Service Unit coordinator (aka, Group Benefits Specialist): Key contact person for most claims-related questions. The implementation process will consist of the following: Initial Evaluation Planning Connectivity Information Membership 4

8 ID Cards Transmission and Disposition File Layouts Implementation and Testing Downloading Electronic Files Production Provider Communication Member Communication Initial Evaluation The first step in the implementation process involves an initial evaluation, both on BCBSIL and the account s part. BCBSIL will meet with the account to review its internal capabilities. Following the initial meeting, both BCBSIL and the account should evaluate the information obtained and come to a mutual agreement regarding a target implementation date. This date should be based on a common understanding of the level of effort involved to implement the process. Planning Once the initial evaluation has been completed and the target implementation date has been established, further meetings will be held between the account and BCBSIL in order to completely define roles and responsibilities for the process. In addition, the BCBSIL Marketing Support representative will develop an implementation plan which will be distributed during the kick-off meeting. This plan will include both testing and other administrative processes associated with the implementation (e.g., ID card issuance, etc.). The target dates for all implementation activities will be reviewed and agreed to by both the account and BCBSIL. 5

9 Connectivity Information In order to access the BCBSIL system which includes Mainframe functions (HPA, TRMN and IMNU) and ALIM, accounts may do so by using a site-to-site VPN connection along with Telnet 3270 terminal software of the account s choosing. Membership The account will be asked to provide BCBSIL with membership information on a scheduled basis in either the BCBSIL BlueStar AEP or the HIPAA 834 Benefit Enrollment and Maintenance layout via an electronic transmission. BCBSIL will use this membership data in order to produce ID cards, route claims if they are received with partial information (see Membership Soft Edits in Chapter 3 for details) and respond to provider inquiries. Note: Shared Claims Processing is not applicable to any person who has selected Medicare as his/her primary coverage. Medicare primary members should not be included on any membership files created by the account for use by BCBSIL. Provider Inquiries Providers may inquire on a member s eligibility, benefits, accumulators or claim status in one of two ways: Phone: Provider inquiries received via phone call regarding a member s eligibility, benefits or accumulators received by BCBS will be redirected to the account office for verification. Provider inquiries via phone call regarding claims status are handled by the local BCBS plan. Internet: Any provider inquiries received via internet will be responded to with the information reported by the account and stored on the BCBS system. Please note that these electronic responses include a disclaimer, Unless otherwise required by state law, this notice is not a guarantee of payment. Benefits are subject to all contract limits and the member s status on the date of service. Accumulated amounts, such as deductibles may change as additional claims are processed. 6

10 In order to respond to these inquiries, accounts will need to provide BCBSIL with the following information: Eligibility A response to a member s eligibility is provided based on eligibility information submitted by an account on the electronic membership file. See Membership section above for further details on transmitting membership files. Benefits Responses to benefit inquiries are based on benefit information that is housed on the BCBSIL system which was derived from SPDs/Plan Benefit Booklets provided by accounts. This information must be supplied early in the implementation process to allow adequate time to update the BCBSIL system. Any changes made to an account s benefit structure must be reported to the assigned Account Executive as soon as possible so that information given to providers is accurate. Accumulators Responses to accumulator inquiries are based on accumulator information housed on the BCBSIL system. Accounts are required to transmit frequent electronic data files to BCBSIL with accumulator information for all members. This file should have a prefix of SCPACCM and should be transmitted via the account s Illinois production Axway mailbox. Claim Status In order to accurately update the provider, accounts must either send a pended Disposition Record with a Pend Code to BCBSIL or finalize the claim. Therefore, it is imperative that accounts return claims on a timely basis with a valid Pend Code or payment information. Providers may also call the account s office with questions concerning any claims which are out of network. Accounts may receive calls for claims status from a provider when a claim is out of 7

11 network or from the BCBSIL FSU when a claim has not been finalized and additional information is needed. ID Cards The BCBS ID card is the most important tool for members. The account s communications to its members should stress the importance of showing providers their new BCBS ID card so that they can be identified as a BCBS member. When visiting a PPO provider, members receive the following benefits: Direct claims submission to the local BCBS plan by the PPO provider No balance billing to the member for any amounts in excess of the BCBSIL PPO fee schedule The ID card will include the following information: claim filing instructions, inquiry telephone numbers and pre-certification requirements (if applicable). The card must contain the standard BCBS logo. The account s name and/or logo may be included on the card if the account so desires. An ID card mock-up will be created by BCBSIL, which is subject to the account s review. ID cards are usually created and distributed to members approximately two weeks prior to the implementation date. If a member has presented his/her BCBS ID card and the contracting provider is directing the member to file the claim, the BCBSIL Account Executive should be notified. He/she will contact a Provider Affairs representative who will contact the provider in question. It is the responsibility of BCBSIL to ensure that providers are providing service in accordance with the PPO contract. Transmission and Disposition File Layouts Accounts must develop a process to upload claims data received on the Transmission File into its internal adjudication system. In certain instances, the account may need to develop programming that maps specific code values received on the 8

12 Transmission File to internal codes that are specific to the their internal system. BCBSIL uses the HIPAA 837 layout to transmit claims data. Where necessary, BCBSIL incorporated proprietary claims data required for Shared Claims Processing. For finalized and Illinois pended claims as well as BlueCard pended claims, the Disposition File is the tool used to receive this information. For BlueCard claims, the Disposition Record will be created when the claim is processed either through HPA or ALIM. It should be noted that accounts should return a pended claim within 30 days. Refer to Chapter 5 for details on processing claims via HPA and ALIM. It is crucial that the account understand each of the file elements. If the elements are reviewed and understood in the initial stages, concerns can be addressed early in the implementation, which will ease the claims testing process. Implementation and Testing The exchange of claims data between BCBSIL and the account must be thoroughly tested through the transfer of test Transmission, Disposition and Reject Record files both for original entry claims as well as adjustments. Meetings and/or conference calls will be scheduled on a regular basis to monitor testing progress. A test schedule will be utilized as a tracking mechanism to monitor the status of each file through the entire test cycle (Transmission, Disposition and Reject files). Concurrent with the testing process, other administrative activities required to implement the process will also take place. The status of these items will continue to be monitored through the use of the Implementation Plan, and will be included as agenda issues for regularly scheduled meetings and/or conference calls so that all parties are fully updated. The implementation and testing phase is completed when the account and BCBSIL are fully satisfied with the test results and mutually agree that the process is ready to move into the production phase. 9

13 Downloading Electronic Files In order for the account to obtain an Illinois or BlueCard Transmission File, or any other electronic file, they must download the file from Axway. Accounts will be assigned separate mailboxes for Illinois and BlueCard claims and membership files. Axway may be accessed by using an SFTP connection to the internet. Detailed instructions for accessing Axway as well as electronic file prefix names and definitions may be obtained on the SCP Web site at Production The meetings and conference calls that are a part of the testing phase will continue through the initial weeks of production until both BCBSIL and the account are satisfied that the process is stable and that the claims are flowing through the system smoothly. In addition, the Implementation Team will monitor the flow of claims for the first several months to identify and quickly correct any initial production issues. Disposition File rejects are monitored as this is the area where data problems are typically first identified. To prevent a backlog of claims or delays in provider payment, special attention will also be paid to the number of Disposition File Records that are returned by the account to BCBSIL and the frequency. System Enhancements Twice per year, once in the Spring and once in the Fall, BCBSIL will make systems-related updates and improvements. To help inform accounts technical support staffs and their vendors in advance of upcoming systems changes and other technical news, BCBSIL developed Tech Specs. This bi-annual newsletter is distributed to accounts, their vendors, consultants and TPAs exclusively via . It may also be found on the SCP Web site, 10

14 Provider Communication Shared Claims Processing is transparent to the providers. A Shared Claims Processing claim is treated just as any other BCBS claim and is handled per the contracted conditions. Member Communication The account will continue to answer members questions and to educate them about various aspects of the new arrangement with BCBS. Member Inquiries The account will be the primary source of information for the members. This includes data such as accumulator status, deductible status, claim status, membership status, claim filing procedures, etc. To receive the most current PPO provider status, accounts should direct their members to log on to This is an excellent means for members to locate a provider or to check whether their existing provider is in the BCBS PPO network. 11

15 Chapter 3 Claims Pre-Adjudication T he purpose of the Transmission File is to supply the account with the necessary data to adjudicate claims. The Transmission File also helps to standardize the claims adjudication process so that BCBS is always the first party to begin processing. This assures that BCBS applies the necessary pre-adjudication edits prior to transmitting claims to accounts. The following is an outline of the two sections in this chapter. BCBSIL Claims Pre-Adjudication Claims Routing Claims Data Editing Account Claims Pre-Adjudication Eligibility and Benefit Verification COB Programming PPO Indicators/Payment Levels Duplicate Checking Requests for Additional Information 12

16 BCBSIL Claims Pre-Adjudication Claims Routing All claims, Illinois and BlueCard, should be sent directly to the local BCBS plan if the member shows the provider his/her ID card. For Illinois, claims are transmitted from BCBSIL to the account. For BlueCard, the local BCBS plan will then transmit the claim record to BCBSIL who then transmits the claims to the accounts. Refer to figures 3.1 and 3.2 on the following two pages for Illinois and BlueCard flowcharts illustrating this process. However, because not all members do so, some claims are inevitably routed to the account s office. Accounts should return these claims to providers with a letter instructing them to file directly with BCBS. This approach may correct future filing errors if the providers have not updated their patients files. If a significant number of claims continue to be filed to the account, BCBSIL can assist the account in creating a communication piece to send to the members that encourages them to show their BCBS ID card at the time services are rendered. Claims Data Editing When BCBS receives claims, pre-adjudication edits are applied. These include the following steps: Verification of provider data Application of membership soft edits Validation of Procedure and Diagnosis Codes Application of Claim Edits Pricing Establishment of payment direction Duplicate claims checking An understanding of these steps will provide the account with background information about the key fields on the Transmission File Record. 13

17 Shared Claims Processing Flowchart (Illinois Process) The account returns any misrouted claims back to the provider for electronic submission. Hospitals/ physicians send claims to BCBSIL BCBSIL verifies provider information and prices the claims Payments are made to Hospitals and PPO physicians when necessary BCBSIL processes the postadjudication data Provider Claim Summaries are created for providers BCBSIL transmits the claims to the account The account verifies eligibility and adjudicates the claims The account transmits processed claim data to BCBSIL Payments are made to members if necessary Explanation of Benefits are sent to members Figure

18 Shared Claims Processing Flowchart (BlueCard Process) 2. Local Plan transmits claims data to BCBSIL 4. BCBSIL transmits claim file to account. Discount/pricing information not included. Account s Claim System 1. Local BCBS plan receives claim. 9. Payment issued to providers/ transmit check data to BCBSI. 3. BCBSIL reformats data into common format. 8. Account updates internal claims history with discounted payment information. 5. Account processes claim to determine preliminary adjudication results. 8. Claims disposition information transmitted to local BCBS plan. BCBS Plans Flow Account s Flow 7. Pricing Software on BCBSIL mainframe calculates discount. Generates disposition record (to local BCBS plan) and priced adjudication results (to the account). Pricing results returned to update account s system Pre-adjudication results to BCBS pricing module 6. Account s claim system invokes pricing module on BCBSIL system passing preliminary adjudication results. Figure

19 Verification of Provider Data BCBS will verify the provider numbers and assure that the appropriate address is included on the claim transmitted to the account. Please note that this address is not necessarily the office where the provider practices. Providers may submit claims using a billing service or an address, such as a clinic, other than where the member received services. Membership Soft Edits To prevent incorrect or invalid member data being passed on a claim, possibly leading to a delay in processing or inappropriate denial, BCBSIL uses membership soft editing capabilities, or Soft Edits. BCBSIL validates membership data submitted on claims by providers without denying the claim for membership reasons. These edits also allow BCBSIL to correct erroneous claim data and flag records that do not match BCBSIL eligibility records on file. The direct benefit is improved data quality to clients which results in fewer denied claims. Claims are passed through a series of matching data criteria in the Soft Edits process. The edits validate the claim data against the following data BCBSIL receives from account membership files: First Name Sex Effective Date Middle Initial Subscriber ID Number Zip Code Last Name Date of Birth Group Number Relationship Code If a positive match is found, the membership information provided by accounts will be utilized to apply accurate membership data within the BCBSIL internal system. This data will be passed to accounts in the membership fields found on the Transmission File layout along with a Membership Record Indicator of 1. Please note that accounts have the ability to update membership data on a claim record via a disposition file for Illinois claims or through HPA or ALIM for BlueCard claims. If a positive match is not found or multiple membership records are found on the BCBSIL system, a 16

20 Membership Record Indicator of 0 or 2 will be applied to the claim but no membership data will be changed. To further identify what information, if any, BCBS altered on a claim prior to transmitting the claim to the account Patient Information fields on the HIPAA 837 layout will be populated with either Y or N. In order for the Soft Edits process to provide accurate membership data on claims, BCBSIL will need to hold accurate membership data internally. The requirements for all membership files are as follows: All of the previously mentioned fields must be populated. No defaults can be used on any of the previously mentioned fields. Membership files must be sent frequently enough to provide BCBSIL with the most current data. BCBSIL recommends that accounts send files once per week. Dependent data must be included on all membership files. Validation of Procedure and Diagnosis Codes Edits are performed on the claim to ensure that only valid national codes (i.e., CPT, ICD-9/ICD-10, HCPC, Revenue, etc.) are applied to the claim before sending it to the account. Accounts utilizing national coding structures on their internal processing systems will occasionally experience problems with matching specific codes on incoming claims when annual updates to the coding structure occur. If the account utilizes these codes, they should stay current with any annual updates to prevent such editing problems. Application of Claim Edits BCBSIL uses an automated claim auditing system to evaluate professional billing and CPT coding for accuracy. This software package ensures that BCBSIL is adjudicating and reimbursing services in a manner consistent with coding protocols established by Health Care Financing Administration (HCFA) and the American Medical Association (AMA). Below is a description of some of the billing practices edited for. 17

21 Unbundled Procedures Procedure unbundling occurs when two or more CPT procedure codes are used to indicate a surgery that was performed, when a single comprehensive CPT code exists that accurately describes the entire surgery performed. These errors are automatically identified and unbundled codes are rebundled to the correct CPT/HCPC code. Incidental Procedures An incidental procedure is one that is performed at the same time as a more complex primary procedure where the incidental procedure is clinically integral to the performance of the primary procedure. For this reason an incidental procedure should not be billed or reimbursed separately. All procedures that are considered incidental are denied when billed with related primary procedures on the same date of service. Mutually Exclusive Procedures Mutually exclusive procedures exist when a provider bills separately for two or more procedures that are usually not performed during the same patient encounter on the same date of service. The correct procedure for reimbursement is selected and identified. Medical Visits Medical visits are separate charges that should be included in another procedure. When it is included in another procedure, the separate charge is denied except when it is billed with modifier 25. Age/Sex Edit The system will not allow procedures for patients that are inappropriate due to age or sex. Assistant Surgeon The system will edit for the appropriateness of Assistant Surgeon charges. 18

22 Pricing Local BCBS plans will price claims according to their provider s PPO status and the type of service performed. Specifics regarding how claims are priced are relative to the local plan. The following is a table which provides an overview of pricing procedures for both the Illinois and the BlueCard processes. Detailed information regarding each process can be found below the table. For specifics on how to apply pricing for Illinois claims see Chapter 4 and for BlueCard claims see Chapter 5. Illinois PPO Balance Billing PPO Ind Contracting Balance Billing PPO Ind Non- Contracting Balance Billing PPO Ind Institutional Discount % No Y Discount % No Y % of Medicare Yes N or O Professional BCBSIL Fee Schedule No Y n/a n/a n/a BCBSIL Fee Schedule Yes N or O BlueCard PPO Balance Billing PPO Ind Contracting Balance Billing PPO Ind Non- Contracting Balance Billing PPO Ind Institutional Host Plan Pricing No 3 Host Plan Pricing Yes 1 % of Medicare or Billed Charges or Host Plan Pricing* Yes 0 or 9 Professional Host Plan Pricing No 3 Host Plan Pricing Yes 1 % of Medicare or Billed Charges or Host Plan Pricing* Yes 0 or 9 * BCBSIL will transmit billed charges on the transmission file to the account. Once HPA or ALIM is accessed (see Chapter 5 for detailed information on processing HPA and ALIM claims) the local BCBS plan pricing is available. 1. Illinois Process: 19

23 PPO Network Providers - These are providers who have a signed PPO contract with BCBSIL. Their pricing procedures are as follows: - For institutional claims, accounts will receive a discount percentage to apply to each line of service. Members may not be balance billed for any amount exceeding the discount amount. - For professional claims, the BCBSIL fee schedule will be applied to each service line. Any amount over this fee schedule will be indicated as an ineligible amount on the Transmission File, with a relevant Ineligible Reason Code. The amount passed is based on a percent of billed charges. The percentage amount depends on the provider s zip code, offering accounts a reasonable market price in the area where services are rendered. Members may not be balance billed for any amount exceeding the fee schedule. Note: Throughout this manual whenever a service level position number is stated, it is referring to the first line of service for illustration purposes. Contracting (Non-PPO) Providers - These are providers who are not in the BCBSIL PPO network; however, they may have another contractual arrangement with BCBSIL offering some type of discount amount. Their pricing procedures are as follows: - For institutional claims, accounts will receive the discount percentage, if applicable, to apply to each line of service. Members may not be balance billed for amounts exceeding any available discount amount. - All non-ppo professional claims are passed as non-contracting providers. See below for a full description. 20

24 Non-Contracting Providers - These are providers who are not in the BCBSIL PPO network and they have no contractual agreements with BCBSIL. Their pricing procedures are as follows: - For institutional and professional claims, a fee schedule will be applied to each line of service. Any amount over this fee schedule will be indicated as an ineligible amount on the transmission file, with a relevant Ineligible Reason Code. The amount passed is based on a percent of the Medicare fee schedule. Since non-contracting providers do not have a PPO contract with BCBSIL, they may balance bill members. 2. BlueCard Process: Note: Per the Network Administration Agreement, accounts may not use billed charges as an alternative pricing option. PPO Network Providers These are providers who have a signed contract with BCBS. Their pricing procedures are as follows, depending on the local plan s pricing practices: - For institutional and professional claims, the pricing procedure may vary for each BCBS plan. Members may not be balance billed for amounts exceeding the discount. The following is a list of possible pricing procedures for institutional and professional PPO network claims: - Percent of charges: The percentage discount applied to the covered or billed charges. This method may be used for institutional claims at the claim or line level. - Percent of allowed amount per category of service: The percentage discount based on the local BCBS plan s rate, rather than billed charges. This rate represents the price for the service, regardless of the number of units for 21

25 the service. This method may be used at the line level. - Percent of allowed amount per unit of service: The percentage discount based upon the local BCBS plan s rate, rather than billed charges. This rate represents the price per unit of service provided. This method may be used at the line level. - Per diem: The all inclusive daily reimbursement rate accepted as payment in full for accommodations as well as most, if not all, ancillary services incurred during the stay. This method may be used for institutional inpatient claims at the claim or line level. - DRG (case allowance): Diagnosis Related Groups (DRG) is the fixed rate established by case allowance method and is accepted as payment in full for accommodations and ancillary services incurred during the stay, regardless of length of stay. This method is used for institutional inpatient claims priced at the claim level. - Case allowance/percent of charges: This method is a combination of case allowance (inclusive) pricing with percent of charges pricing. Subscriber liability is based on the case allowance and the BCBS liability is based on the percent of charges discount. This method is used for institutional inpatient claims priced at the claim level. - Flat fee or allowance per category or unit of service: The fixed dollar amount accepted as payment in full for category of service. This amount represents the ceiling or maximum dollar amount that would be allowed by the local BCBS plan for a given category/unit of service. The allowed amount maybe zero priced or may exceed the billed charge for negotiated rates. For UCR reimbursed 22

26 services, when the allowed amount is greater than the billed charge, the local BCBS plan must reduce the allowed amount to equal the billed charge. This method is used at the line level. - Multiple service allowance: An allowance for a specific ancillary or procedure that includes other associated ancillaries and/or procedures. The local rate for the primary ancillary or procedure is specified on the first line of the claim and a local rate of zero for the ancillaries or procedures is included in the rate on additional lines. This method is used for institutional outpatient and professional claims at the line level. - Multiple service allowance/percent of charges: Combination of multiple services (inclusive) pricing with percent of charges pricing. Subscriber liability is based on the inclusive price and the BCBS liability is based on the percent of charges discount. This method is used for institutional outpatient and professional claims at the line level. Contracting (Non-PPO) Providers These are providers who are not in the BCBS PPO network; however, they may have another contractual arrangement with BCBS offering some type of discount amount. The pricing procedures are as follows: - For institutional and professional claims, refer to the BlueCard PPO network claims section for possible pricing methods. Members may be balanced billed for amounts exceeding the discount depending on provider contracts with the local BCBS plan. Non-Contracting Providers - These are providers who are not in the BCBS PPO network and they have no contractual agreements with BCBS. Accounts have three options for pricing out-of-state non- 23

27 contracting provider claims: Utilizing BCBS pricing, paying billed charges or paying based on the account s internal fee schedule. Details on how to process these claims are available in Chapter 5. Their pricing procedures are as follows: - For institutional claims, BCBSIL will pass billed charges, local BCBS plan pricing or a fee schedule. Since these providers do not have a contract with BCBS, they may balance bill members. - For professional claims, billed charges or the local BCBS plan s pricing will be passed. Since these providers do not have a contract with BCBS, they may balance bill members. Establishment of Payment Direction The Transmission File will indicate the party that should receive the payment on the claim using a Payment Payee Code. The appropriate values for the Payment Payee Code are as follows: 1. A value of Y indicates that payment should be sent to the provider by BCBS. In instances in which the Payment Payee Code is set to Y, the account is required to return a Disposition Record to BCBSIL so that payment can be made to the provider. The Payment Payee Code will be set with this value in the following instances: Institutional services where the member has not issued payment up-front to the provider or the provider has an alternate contract with BCBS. Professional services where the member has not issued payment up-front to the provider or the provider has an alternate contract with BCBS (i.e. ambulatory services). Professional services where the member has paid a portion of the total charge to the provider. Even though the member paid a portion of the claim to the provider, BCBS will still issue full payment to the 24

28 provider. It is up to the provider to reimburse the member their paid portion. Accounts should notify their BCBSIL Group Benefits Specialist in these situations so that they may investigate why the provider asked the member to pay a portion up front. For these claims, the Patient Paid Amount field will have a dollar amount on the Transmission Record. 2. A value of N indicates that the account should make payment to the member. Accounts are not required to return a Disposition File for Illinois claims. For BlueCard claims, accounts must return a Disposition Record. The Payment Payee Code will be set with this value in the following instances: Institutional services where the provider is not contracted with BCBS. Professional services where the provider is not contracted with BCBS, or all non-solicited providers who don t have an alternate contract with BCBS. The solicited provider network will vary by plan for BlueCard claims; however, BlueCard non-solicited provider claims will be identified with a PPO indicator of a 9. Duplicate Claims Checking Logic will be applied to determine if a claim has been previously submitted based on BCBSIL s internal records. This logic varies for exact match duplicate claims versus partial match duplicate claims. 1. Exact match duplicates: For Illinois claims, BCBSIL will deny duplicate claims if the duplicate criteria matches exactly and if the duplicate claims were transmitted by the provider less than 30 days apart from one another. If, however, the duplicate claims were transmitted more than 30 days apart from one another, they will both be forwarded to the account. For BlueCard claims, BCBSIL will deny duplicate claims only if they have been finalized. 2. Partial match duplicates: Should any of the duplicate checking criteria differ, BCBSIL will transmit the claim to 25

29 the account. An Ineligible Reason Code value of SDU (suspected duplicate) or SAJ (suspected adjustment) will appear on the line of service of the claim where the information differs. If a duplicate claim submission has not yet been finalized by the account, the subsequent claim will not be flagged with these indicators. This is true for both Illinois and BlueCard claims. Note: It is the account s responsibility to read these flags and make the final determination as to whether or not a claim is a duplicate based on historical information maintained on the account s internal claims adjudication system. Account Claims Pre-Adjudication Eligibility and Benefit Verification The account retains responsibility for verifying eligibility and member history. They will ultimately determine whether the member is eligible for claims submitted on the Transmission File. The account also retains responsibility for determining which specific services are covered under its program. COB Programming If the member has coverage with another group insurance carrier, the account is responsible for coordinating benefit coverage. If information is received on an individual claim regarding other insurance carrier names and/or payments, that data will be included on the Transmission Record. The account s system should be programmed to read these fields and utilize this data on the incoming record. PPO Indicators/Payment Levels Accounts are responsible for calculating deductibles, coinsurance amounts and any benefit maximums that may be applicable. As the appropriate coinsurance percentage is based on the PPO status of the provider as of the date of service, the account s adjudication system should be programmed to read the PPO Indicator field on the incoming Transmission File Record. Note: The account s system should be programmed based on this indicator, not on any internal PPO Status Indicator that may be 26

30 loaded on their internal provider file database, regardless of the source of data. Requests for Additional Information Once the account receives claims from BCBSIL, they must determine if any additional information is needed to process the claims based on information stored at the account and data included on the claim records. Member Information If additional member information is required to adjudicate a claim, the account is responsible for requesting and pursuing it from the member. The account should decide how to request this information from its member. No requests can be made using BCBSIL letterhead. Provider Information If additional information is needed from providers, BCBSIL will request the information on the account s behalf. They would simply create a transmittal request and send it to the FSU. There are two options for submitting transmittals. Accounts can use either one or both of the transmittal methods to send requests to BCBSIL. Listed below are the requirements for each method. Fax to image Mainframe on-line entry 1. Fax to image: Accounts may simply fax transmittal forms to (312) (for Chicago FSU accounts) and (217) (for Danville FSU accounts). This number routes the forms to the BCBSIL image system. The form is then routed to the appropriate FSU location and then assigned to an examiner. These forms are available through the FSU. However, should accounts decide to create their own form they should make sure that the letters NADJ are typed in the upper left-hand corner in a large font size. Also, each transmittal should be limited to one member. It may include several claims as long as there is only one group and member number. 27

31 2. Mainframe on-line entry: The mainframe on-line entry process (aka, TRMN) provides users with the ability to browse, respond to, or perform same-day deletions of transmittal requests on-line. Use of the mainframe on-line process requires that users initiate mainframe connectivity and obtain the appropriate security access. This access may be obtained through a member of the Implementation Team and training is conducted by the FSU. Requirements for this process are as follows: - Develop internal procedures governing use of the online application - Develop internal procedures governing the processing of responses via the on-line application - Develop internal process to audit transmittal activity - Obtain security access by contacting the appropriate Marketing Support representative - Develop the capability of initiating a mainframe session 28

32 Chapter 4 Illinois Claims Adjudication O nce the Transmission File Records have been received and uploaded into the account s internal adjudication system, they are responsible for all claims adjudication processes. This includes the following steps: Application of Pricing Data Claims Balancing COB Processing Pended Claims Illinois Adjustments Application of Pricing Data As indicated in Chapter 3, BCBSIL will pass an Eligible Amount for each service line on the Transmission File Record. BCBSIL will price claims according to the provider s PPO status and the type of service performed. The following guidelines should be utilized when applying BCBSIL pricing: 1. PPO Network Providers For institutional claims, on each line of service, a discount percentage will be indicated. This 29

33 percentage represents the BCBSIL savings percentage applicable to that claim. The percentage indicated in this field should be applied to reduce the Eligible Amount for that line of service. It should be noted that the Eligible Amount field in the Disposition File Record should not reflect payment reductions caused by interim discounting. The actual amount that is deducted from the Eligible Amount field in the Transmission File Record should be saved for reporting on the Disposition File Record as the Interim Discount Amount. Please note the following: - If the Eligible Amount changes in the adjudication process (e.g., the member has reached a benefit maximum), the account will need to recalculate, or recalibrate, the Discount Amount based on the new Eligible Amount. Note: For PPO claims, accounts may not alter or change any of the pricing data indicated by BCBSIL and should apply it as indicated on the Transmission Record. For professional claims, when a service exceeds the BCBSIL fee schedule, the dollar amount in excess of the fee schedule will be indicated as an Ineligible Amount and the Ineligible Reason Code field will contain the appropriate value. Payment for PPO services must be based on the fee schedule amount. 2. Contracting (Non-PPO) Providers For institutional claims, the application of this pricing is handled the same way as pricing for the PPO network providers. Professional claims are either PPO or Non- Contracting. 3. Non-Contracting Providers Pricing application for institutional and professional claims is handled the same way as professional claim pricing for PPO network claims. As mentioned in the previous chapter, the difference is that these providers hold no contract with BCBSIL; therefore, 30

34 members may be held responsible for any amount over the BCBSIL fee schedule. Claims Balancing All dollar fields on the Disposition Record should balance based on standard BCBSIL balancing rules. These rules are as follows: Service Level Balancing Total Charge - Assumed Ineligible Amount* Eligible Amount Eligible Amount Discount Deductible Coinsurance OI Savings Medicare Savings - Worker s Compensation Savings Payable Amount *This is an assumed amount since the Eligible Amount is passed on the Disposition File. Claim Level Balancing The sum of the Payable Amounts for each service line must equal the Total Payment Amount of the claim. For Institutional claims, the discount amount must equal zero if the Other Insurance savings, Medicare savings or Worker s Compensation savings are greater than zero. Claims that do not balance or do not meet other editing criteria internal to the BCBSIL post-adjudication process will be rejected and re-transmitted back to the account for correction. This editing and rejection process is described in further detail in Chapter 6, Claims Post-Adjudication. 31

35 COB Processing Please note the following rules to be applied in COB situations: Professional claims: Regardless of whether or not another carrier has made payment on a claim, the BCBSIL fee schedule applies on all PPO network professional claims. Institutional claims: If the account is paying secondary to another carrier on a claim, they are not entitled to the BCBSIL facility discount. The savings incurred, as a result of the other carrier making payment, should be reflected on the Disposition File. In addition, the discount percentage sent on the Transmission File from BCBSIL should not be applied to the claim. If the account is paying primary benefits on a claim for which it is the secondary carrier, they should apply the provider discount to the eligible dollars on the claim. This typically occurs when the entire payment made by the other carrier has been applied to the member s deductible. The claim should be adjudicated per the normal procedures. If the member has other group coverage for which BCBSIL is the carrier, the other insurance payment information can be coordinated internally by the BCBSIL Full Service Unit (FSU) without having the member resubmit paperwork after benefits are applied under the first contract. Instead of the member resubmitting a claim form to BCBSIL to coordinate coverage under the second contract, the FSU will work with the appropriate departments to process the claim under both contracts upon the initial submission of the claim. Dual membership coverage can be defined as two family members (married/domestic partners and/or dependents) who are employed by the same company and who are both insured by BCBSIL. When BCBSIL receives a claim for one family member, the Full Service Unit (FSU) will increment the claim and send a second claim under the other family member s coverage (for Illinois) or request a second claim from the other BCBS plan (for BlueCard). In order to provide this service, BCBSIL asks that accounts provide an updated dual coverage 32

36 member list to their designated FSU Group Benefits Specialist on a quarterly basis. Pended Claims A Disposition File Record is required from the account for any claim that was transmitted with a Payment Payee Code value of Y which must be delayed at the account s office. BCBS must receive notification that a claim has been delayed in order to respond appropriately to any provider inquiries regarding claim status. Both Illinois and BlueCard claims will use the HIPAA 835 layout to transmit pended claims information. There are four occurrences for Pend Code Reasons allowing for five characters per occurrence. Pend Code Reasons should be populated on the Disposition File. In order to respond to HIPAA 276 (claim status) requests with a 277 (claim status) response, BCBSIL must receive a HIPAA Pend Code. Accounts will need to pass this code in the first Request for Information (RFI) Letter Code field on the Disposition File Layout. While these codes may be specific enough for providers, they may not be as specific as the codes that accounts would like to use. For this reason, accounts may transmit BCBSIL preestablished codes or its own internal codes in addition to the HIPAA Pend Code. These additional codes may be sent in the second, third and/or fourth position of the RFI Letter Code field. If the account chooses to use its internal codes, the specific codes and their explanations must be forwarded to the account s designated Marketing Support representative. Should a claim contain a code other than a HIPAA Pend Code in the first field, the claim will reject with Reject Reason Code RC009 RFI Letter Code invalid. For a full list of Reject Reason Codes, refer to the SCP Web site at Illinois Adjustments For all BCBS initiated adjustments a Transmission Record representing an adjustment to the original entry claim will be 33

37 created and transmitted to the account. For all adjustments, accounts are required to send a Disposition Record whether it is through a Disposition File, HPA or ALIM. Adjustment Types There are two main categories of adjustments: Non-credit adjustments Credit adjustments Non-credit adjustments involve claim reprocessing situations that are unrelated to returned monies. Credit adjustments are created when BCBSIL either receives money back from a provider or issues an up-front credit. For non-up-front credit adjustments, the adjustment will not be initiated unless the money in question has actually been returned to BCBSIL by the provider. An adjustment must be processed to the original claim for the account to receive a credit on its billing. Depending on the type of claim scenario, a particular adjudication process is required to properly balance the adjustment. Following are some general adjudication guidelines to be followed when processing adjustments. Non-Credit Adjustments To initiate a non-credit adjustment, with the exception of an R06 adjustment which the account initiates from their office, the account must make a request via the transmittal process to the BCBSIL Full Service Unit (FSU). See Chapter 3 for detailed instructions regarding each option. An adjustment claim record will be created and transmitted to the account within (3) business days of BCBSIL receiving the request. The following Adjustment Reason Codes identify non-credit adjustment claims. R01: All dollars on the original claim were denied. The account requests the claim to be re-opened to readjudicate the charges on the original claim. Please note that the R01 adjustment is similar to an original 34