BlueCare Plus HMO D SNP Remittance Advice Overview

Transcription

1 HMO D SNP Remittance Advice Overview 1

2 This Guide was current at the time it was published or uploaded onto the web. This Guide is a general summary that explains certain aspects of the Program; however, this is not a legal document and does not grant rights or impose obligations. will not bear any responsibility or liability for the results or consequences of using this summary guide. Providers are responsible for the correct submission of claims and response to any remittance advice in accordance with current laws, regulations and standards. This document is designed as a self-help resource for providers. Use of this guide offers the user the following benefits: Easy access to general information about the RA; Increased ability to understand and interpret the reasons for denials and adjustments; Reduction in the resubmission of claims; Rapid follow-up action, resulting in quicker payment; and A useful tool for training new staff or a refresher for experienced staff. 2

3 What is the Remittance Advice The Remittance Advice (RA) is a document supplied by that provides notice of an explanation for payment, adjustment, denial and/or uncovered charges of a submitted medical claim. There are two types of Remittance Advice ELECTRONIC REMITTANCE ADVICE (ERA) Electronic Remittance Advice (ERA) Standard Remittance Advice (SRA) DETAILED PAYMENT INFORMATION REQUIRED ELECTRONIC SUBMISSION MORE EFFICIENT PROCESSING GUARANTEED RECORD OF RECEIPT EFFICIENT CLAIMS TRACKING SUBMIT SECONDARY CLAIMS MAY ACCESS THROUGH BLUEACCESS FOR MORE INFORMATION CONTACT ebusiness Enrollment Support The ERA allows the ability to post payment information automatically and assists in identifying denials made during the billing to make necessary corrections. An electronic remittance advice (ERA) is the electronic version of payment explanation, which provides details about providers' claims payment. If the claims are denied, the remittance advice would contain the required explanations. The industry standard for sending ERA data is the HIPAA X12N 835 standard. BCBST provides Electronic Remittance Advices (ERAs) in the ANSI Version 5010 format. The RA provides justification for the payment, as well as input to your accounting system/accounts receivable and general ledger applications. The codes on the RA identify any additional action you may need to take; for example, an RA code (RAC) may indicate you may need to resubmit the claim with corrected information The RA provides detailed payment information about a health care claim (s) and describes the payment; it also features valid codes and specific values that make up the claim payment. Once you receive the RA you may, Post the decision and payment information automatically when a compatible provider accounts receivable software application is being used; and/or Identify reasons for any adjustments, denials or payment reductions

4 ELECTRONIC REMITTANCE ADVICE (RA) Helpful Links ANSI Version 5010 ebusiness Tools & Resources Technical Information Blue Core System Blue Access for Providers Electronic Claims and Electronic Funds Transfer Getting Started with ebusiness FOR MORE INFORMATION CONTACT ebusiness SOLUTIONS Enrollment Support (Option 2) ERA advices are not easily readable while in ANSI Version 5010 format. Contact your software vendor if you would like to know if your software can translate or automatically post account information from the ERA. ERA files can be downloaded using the BCBST s Secure File Gateway (SFG). Providers should contact their vendor prior to requesting ERAs to ensure their vendor can support translation of the ERA. Detailed ANSI Version 5010 specifications for the ERA are available at edi.com In addition, providers may view remittance advice information on BlueAccess, the secure area of bcbst.com. The Remittance Advice information will be online PDF versions of provider s paper remits. 835 Version 5010 Electronic Remittance Advice

5 STANDARDREMITTANCE ADVICE PROFESSIONAL CLAIM TheRemittanceAdviceisdivided intothreemajorcolumns PatientInformation ClaimInformation PaymentInformation Field Description LineofBusiness MV01representsBlueCarePluslineofbusiness Remit/CheckDate ThisfielddisplaysdatetheRAisissued InternalProvider Number Thisfielddisplaysthemedicalrecordnumber(MRN) orpatientaccountnumberthatwassubmittedon theclaimform NPINumber ThisfielddisplaystheassignedNationalProvider Identifier(NPI)number TaxIdentification Number IdentificationnumberusedbytheInternalRevenue Service(IRS)intheadministrationoftaxlaws CheckNumber IndicatesthechecknumberassignedtotheRA RemittanceNumber SequentialnumberassignedtotheRA PageNumber Numberofpagescontainedintheremittanceadvice Bluecareplus.bcbst.com BlueCarePlus

6 Field Last Name Description This field displays the last name of the BlueCare Plus member First Name This field displays the first name of the BlueCare Plus member Patient Account This field displays the medical record number (MRN) or patient account number that was submitted on the claim form Member ID This field displays the assigned member identification number for the member Field Description Claim Number Recvd DT This field displays the claim number assigned to the claim at the time it is received by BlueCare Plus This field indicates the received date for claim processing Serv Prov The field indicates the servicing provider Date of Service From/Thru Indicates the start date of service and the last date of service on the processed claim Procedure/Modifier Total Charges Indicates the HCPC, CPT and modifier used This field indicates the total charges submitted by the provider 6

7 Field Description BLUECARE PLUS DUAL ELIGIBLE will forward claims for TennCare eligible members to the Bureau of TennCare for the processing of member cost sharing. The patient deductible, co pay and/or coinsurance amounts should not be billed to the member except when the member has lost their TennCare eligibility Patient Non Covered Note Contract Write Off Note Patient DED/ COPAY Patient COINS This field indicates the number of non covered days or visits that are submitted by the provider when it is known that the days or visits are not covered by Medicare. Providers do not anticipate payment on non covered days or visits. Remittance Advice remark codes This field indicates an adjustment resulting from a contractual agreement between the provider of services and. Remittance Advice remark codes This field indicates the deductible and co pay for covered services the deductible/co pay should not be billed to the member. This amount will be automatically crossover to TennCare for processing of member cost sharing This field shows the total dollar amount of coinsurance for which the beneficiary is responsible. Other Insurance This field indicates if other insurance or coverage applicable Claim Paid Interest Paid This field indicates the amount paid by This field indicates if any interest has been applied to the amount paid Patient Owes This field will indicate the amount due from the member. members have $0 cost sharing. A file is submitted to the Bureau of TennCare for the copay, deductible and coinsurance. 7

8 STANDARDREMITTANCEADVICE FACILITYCLAIM TheRemittanceAdviceisdivided intothreemajorcolumns PatientInformation ClaimInformation PaymentInformation Field Description LineofBusiness MV01representsBlueCarePluslineofbusiness Remit/CheckDate ThisfielddisplaysdatetheRAisissued InternalProvider Number Thisfielddisplaysthemedicalrecordnumber(MRN) orpatientaccountnumberthatwassubmittedon theclaimform NPINumber ThisfielddisplaystheassignedNationalProvider Identifier(NPI)number TaxIdentification Number IdentificationnumberusedbytheInternalRevenue Service(IRS)intheadministrationoftaxlaws CheckNumber IndicatesthechecknumberassignedtotheRA RemittanceNumber SequentialnumberassignedtotheRA PageNumber Numberofpagescontainedintheremittanceadvice Bluecareplus.bcbst.com BlueCarePlus

9 Field Last Name Description This field displays the last name of the BlueCare Plus member First Name This field displays the first name of the BlueCare Plus member Hosp Chart This field displays the medical record number (MRN) or patient account number that was submitted on the claim form Member ID This field displays the assigned member identification number for the member Field Description Claim Number Received Date Date of Service From/Thru This field displays the claim number assigned to the claim at the time it is received by BlueCare Plus This field indicates the received date for claim processing Indicates the start date of service and the last date of service on the processed claim Rev CD Proc Code DRG Indicates the revenue code to identify specific accommodation and/or ancillary charges Uniform coding that accurately describes medical, surgical and diagnostic services Diagnosis Related Group (DRG) used to assign inpatient hospital services Unit Total Charges Quantifying of services by revenue code category, e.g., number of days in a particular type of accommodation This field indicates the total charges submitted by the provider 9

10 Field Description BLUECARE PLUS DUAL ELIGIBLE will forward claims for TennCare eligible members to the Bureau of TennCare for the processing of member cost sharing. The patient deductible, co pay and/or coinsurance amounts should not be billed to the member except when the member has lost their TennCare eligibility Patient Non Covered Note Contract Write Off Note Patient DED/ COPAY Patient COINS This field indicates the number of non covered days or visits that are submitted by the provider when it is known that the days or visits are not covered by Medicare. Providers do not anticipate payment on non covered days or visits. Remittance Advice remark codes This field indicates an adjustment resulting from a contractual agreement between the provider of services and. Remittance Advice remark codes This field indicates the deductible and co pay for covered services the deductible/co pay should not be billed to the member. This amount will be automatically crossover to TennCare for processing of member cost sharing This field shows the total dollar amount of coinsurance for which the beneficiary is responsible. Other Insurance This field indicates if other insurance or coverage applicable Claim Paid Interest Paid This field indicates the amount paid by This field indicates if any interest has been applied to the amount paid Patient Owes This field will indicate the amount due from the member members have $0 cost sharing. A file is submitted to the Bureau of TennCare for the copay, deductible and coinsurance. 10

11 RA REMARK CODES Remark codes are used to provide additional explanation for an adjustment or convey information about the remittance processing Remittance Advice code descriptions are available at bluecareplus.bcbst.com/providerresources/ BLUEACCESS To view/print your remittance advices, ensure you have access to BlueAccess, BCBST s secure area bluecareplus.bcbst.com. To register, just click on the Register Now link located in the BlueAccess section on the website and follow the simple instructions to obtain a user ID and password 11

12 Customer Service Customer service is more than just a name on a department door. Customer service is more than answering questions quickly and correctly. Customer service is the very heart of, talking personally, individually, to our members and providers. We work as a liaison between members and providers, helping customers access their benefits. Tennessee, an Independent Licensee of the BlueCross BlueShield Association. is an HMO SNP plan with a Medicare contract and a contract with the Tennessee Medicaid Program. focuses on managing care and providing quality health care products, services, and information for government programs. We take great pride in serving the people of Tennessee, both in our products and services and in our numerous outreach activities. simplifying BLUECARE PLUS 1 Cameron Hill Circle Chattanooga, TN ph fax Bluecareplus.bcbst.com. 12