Make the most of your electronic submissions. A how-to guide for health care providers

Transcription

1 Make the most of your electronic submissions A how-to guide for health care providers Enjoy efficient, accurate claims processing and payment Reduce your paperwork burden and paper waste Ease office administration and expenses anthem.com/edi PCEBR3630A (11/10)

2 Table of Contents Are you fully automated?... 2 Four steps to electronic claims filing... 2 Tips for working with a clearinghouse or software vendor... 3 Eliminate dropping claims to paper... 3 Coordination of Benefits (COB), Paperwork (PWK), Notes (NTE) and Adjustments... 4 How to file electronic claims with Coordination of Benefits (COB)... 4 Medicare supplemental claims: always file with the Medicare contractor first... 6 Use NTE to file electronic claims with notes... 6 Use PWK to file electronic claims with supporting documentation... 7 How to file electronic claims with adjustment information... 9 Electronic Remittance Advice (ERA)...11 ERA overview...11 ERA advantages...11 Additional ERA options increase efficiency...11 How to enroll for ERA...11 If you use a vendor or submit to a clearinghouse...11 Electronic Funds Transfer (EFT)...12 Electronic Funds Transfer (EFT) overview...12 EFT advantages...12 How to enroll for EFT...12 Changes after enrollment...12 ERA/EFT points of contact...13 Your EDI Specialists are here to help...13 EDI contact information...13

3 Are you fully automated? Take advantage of all our electronic capabilities so you can: Submit claims consistently Reduce office expenses: administrative, postage, paper forms, print copies and more Reduce costly, time-consuming re-submissions and follow-up Control insurance billing processes like daily reports, claim status and audit trail Increase cash flow and accounts receivables Detect and correct errors before claims are submitted Four steps to electronic claims filing 1 Review our filing requirements. You can find the Anthem HIPAA Companion Guide and EDI Publications online at anthem.com/edi. 2 Work with the practice management, clearinghouse and/or software vendor to determine if the required data is available in your system. If not, add the necessary data fields. To ensure the data will be included in the 837 electronic claim, please test with your clearinghouse or vendor before submitting to us. 3 To help eliminate processing delays, ask your clearinghouse or vendor to review payer edits to ensure required fields will be sent to us error-free. 4 We recommend that your clearinghouse or vendor test any new processes with us before submission. To schedule testing or discuss filing requirements, contact our EDI Specialists at

4 Tips for working with a clearinghouse or software vendor Many EDI vendors have developed or enhanced their software to support sending secondary/coordination of benefits (COB), line/claim notes, adjustments and supporting documentation electronically. Contact your clearinghouse or vendor to help determine what, if any, changes are required and how to get started. Some questions to ask are: Does your software have the capability to submit these transactions electronically? Is an upgrade required? What are the costs? Can the coordination of benefit process automatically identify the secondary payer, insert primary payment information and generate the claim to the other payer? Has the clearinghouse or EDI vendor successfully tested with Anthem? What types of claims is the vendor submitting electronically? If you are currently submitting these types of claims electronically to Medicare, what is required for you to submit to Anthem? Eliminate dropping claims to paper The information contained here can help you, your clearinghouse, practice management and/or software vendor identify filing requirements for: Secondary/tertiary coordination of benefits (COB) Claims requiring supporting documentation Claim and line level notes Adjustments 3

5 Coordination of Benefits (COB), Paperwork (PWK), Notes (NTE) and Adjustments Simply stated, the electronic 837 transaction or ANSI X is a claim in a standard format used across the health care industry as required by the Health Insurance Portability and Accountability Act (HIPAA). Submitting claims electronically saves you time and eliminates the need for paper claims and documents (e.g., supporting documentation or explanation of benefits). In order to submit claims electronically, you must understand our filing requirements, along with the data in your practice management system, clearinghouse, vendor software and the 837 electronic claim format. Understanding electronic submission, opportunities to reduce paper and where to find filing instructions helps office managers work with their staff, clearinghouse and/or EDI vendor to maximize your investment in electronic submission. To help facilitate your discussion with your clearinghouse or vendor, we have listed the required data for submitting professional COB, PWK, NTE and adjustment claims electronically. You do not have to understand the ANSI X format to be able to discuss the various required fields. You only need to understand how to enter the appropriate information into your particular practice management system so that your clearinghouse or vendor can successfully transmit the data to us. How to file electronic claims with Coordination of Benefits (COB) When you have Anthem secondary/tertiary professional claims with coordination of benefits (COB) or other coverage information, you can file these claims electronically and eliminate mailing paper claims. One of the benefits of the electronic claim format (837) required by HIPAA is its COB capability without using paper claims or copies of Explanation of Benefits (EOBs). Done manually, the secondary billing process can be time consuming and potentially error-prone. In the past, EOBs contained payment information for multiple patients. Each patient s payment information was highlighted, with non-relevant information crossed out. Copies would be attached to the claim and mailed to the secondary insurance carrier. Now many vendors offer billing software that can automate this process. We encourage you to work with your clearinghouse and/or software vendor to ensure their systems are HIPAA compliant and can accommodate electronic claims with coordination of benefits. Clearinghouses and software vendors should be familiar with the 837 Implementation Guides and the COB process. An understanding of the data entry process for your particular practice management system will be helpful in ensuring your clearinghouse can successfully transmit the data to us via the ANSI X format. 4

6 Requirements for filing Coordination of Benefits (COB) electronically This document identifies segments required by Anthem to file COB claims electronically with efficiency and no need for paper Explanations of Benefits (EOB). When Anthem is the Secondary or Tertiary payer, use the following segments. You can also refer to the 837I and 837P Companion Documents and 837 Implementation Guides (IG) for technical details. Professional Claims 837P Loop 2320 Other Subscriber Information Loop 2330A Other Subscriber Name Required if information is available Loop 2330B Other Payer Name Loop 2430 Line Adjudication Information Required only when service line adjustments are reported SBR Other Subscriber Information AMT Coordination of Benefits (COB) Payer Paid Amount AMT COB Approved Amount AMT COB Allowed Amount AMT COB Patient Responsibility Amount AMT COB Discount Amount DMG COB Other Subscriber Demographic Information OI Other Insurance Coverage Information NM1 Other Subscriber Name NM1 Other Payer Name DTP Claim Adjustment Date (Only if notes in IG are satisfied) SVD Line Adjudication Information CAS Line Level Claim Adjustments DTP Line Adjudication Date Payer Paid Amount is the amount paid by the other payer (carrier). Approved Amount is the total amount of the claim approved by the payer sending the 837 to another payer. Example: The usual and customary amounts of the primary payer. Allowed Amount is the total amount of the claim allowed by the payer sending the 837 to another payer. Example: The amount paid by the primary payer less the deductible, coinsurance and any co-payments. What does the Patient Responsibility Amount represent? Example: Patient Responsibility is reported in the CAS segments using the code PR (Patient Responsibility); represents the amount of patient liability. What does the Discount Amount represent? Example: Discount Amount represents the contractual adjustment amount reported on the primary payer s EOB. 5

7 Medicare supplemental claims: Always file with the Medicare contractor first Remember to always include: Complete Health Insurance Claim Number (HICN) Patient s complete member identification number, including the three character alpha prefix Member name as it appears on the patient s identification card, for supplemental insurance This will ensure crossover claims are forwarded appropriately. Do not file with us and Medicare simultaneously. Wait until you receive the Explanation of Medical Benefits (EOMB) or payment advice from Medicare. After you receive the Medicare payment advice/eomb, determine if the claim was automatically crossed over to the supplemental insurer. If the claim was crossed over, the payment advice/eomb should typically have Remark Code MA 18 printed on it, which states, The claim information is also being forwarded to the patient s supplemental insurer. Send any questions regarding supplemental benefits to them. The code and message may differ if the contractor does not use the ANSI X payment advice. If the claim was crossed over, do not file for the Medicare supplemental benefits. Use NTE to file electronic claims with notes The professional and dental 837 electronic claim formats contain a notes feature called NTE, a convenient tool for providers to include pertinent claim notes or remarks electronically. The 837 has two fields for notes a claim note (claim-level NTE) and line note (line-level NTE). The number of characters allowed varies depending on the type of 837 (professional or dental). When the supplemental information can be con veyed in the number of characters allowed, use the NTE feature to eliminate filing paper claims with attachments. To ensure prompt payments, include only notes that are necessary to complete processing, such as definition of supply code or a brief description of the service or procedure. Information such as not a duplicate or Anthem Blue Cross and Blue Shield are not necessary and will delay processing. We encourage you to work with your clearinghouse and/or software vendor to ensure their systems are HIPAA compliant and can accommodate electronic claims with notes. Clearinghouses and software vendors should be familiar with the 837 Implementation Guides and the NTE process. An understanding of the data entry process for your particular practice management system will be helpful in ensuring your clearinghouse can successfully transmit the data to us via the ANSI X format. 6

8 Claim-level NTE As its name implies, claim-level notes pertain to the entire claim and should be confined to the number of positions allotted, if possible. However, if a claim-level note requires more characters, continue the note in the line-level note field. This con tinuation is called overflow. Likewise, when necessary, the claim-level note may be used for overflow from the line-level note. Line-level NTE* The line-level note is used primarily to provide information about or a description of the particular service rendered. For example, for CPT code 99070, the description, such as ace bandage, would be included in the line-level note. Please confine line-level notes to the number of positions allotted. However, if a line-level note requires more than the allowed characters, begin the note in the line-level field and continue it in the claim-level note field. 837 Professional Claim Note: 1 occurrence, 80 characters maximum Line Note: 1 occurrence per service line, 80 characters maximum per occurrence (total per claim is 160 characters) *Line notes can be used for unlisted HCPCS or non-specific drug codes and unlisted or non-specific supplies and equipment. Use PWK to file electronic claims with supporting documentation When documentation is necessary to support a claim, electronic submitters can still file claims electronically and fax or mail pertinent paper attachments, thus eliminating the mailing of paper claims with supporting documentation. We will match the electronic claims to the appropriate attachments. This feature of the ANSI X is called PWK or paperwork. We encourage you to work with your clearinghouse and/or software vendor to ensure their systems are HIPAA compliant and can accommodate electronic claims with supporting documentation. Clearinghouses and software vendors should be familiar with the 837 Implementation Guides and the PWK process. An understanding of the data entry process for your particular practice management system will be helpful in ensuring your clearinghouse can successfully transmit the data to us via the ANSI X format. Instructions for Using the PWK Segment to Send Attachments Claims with attachments no longer need to be submitted on paper. When paper documentation or attachments are necessary to support the electronically submitted claim, trading partners should identify the documentation using the PWK (paperwork) Segment at the claim level (Loop 2300). Trading Partners separately mail the actual supporting documentation, accompanied with Anthem s Attachment Face Sheet to Anthem. (Refer to procedures on the next page for details.) 7

9 Attachments can include, but are not limited to, other carrier explanation of benefits (EOB, EOMB), nurses, physician or operative notes, medical records, DME certificate of medical necessity, prior authorization forms, etc. The PWK Attachment Face Sheet is located on anthem.com/edi under the HIPAA Companion Guide in the Appendices. The face sheet includes: 1. Date Claim Transmitted Line of Business (Professional, Institutional) Member s Contract (Subscriber) Number Patient Name Date of Service Provider Name State Where Services Were Rendered Identification Code (Attachment Control #). This Identification Code is an Alphanumeric code created by the provider for his records. To identify and send attachments for medical claims, use the following procedures: Electronic Claim Requirements: Create and transmit the 837 claim according to instructions in the IG and this Companion Document. In Loop 2300 (Claim Information), PWK segment (Claim Supplemental Information) page 214 of the IG, use the following data elements to identify that a paper attachment is forthcoming. PWK01 (Attachment Report Type Code) Use the values indicated in the IG to identify the type of attachment. PWK02 (Attachment Transmission Code) Indicates a code identifying how the attachment will be sent. Anthem accepts supporting documentation by mail only, the value of BM (By Mail) in this data element is the only value accepted. PWK05 (Identification Code Qualifier) Use code value of AC (Attachment Control Number). The data element is required if PWK02 = BM. PWK06 (Attachment Control Number) A value assigned by the provider to uniquely identify the attachment. This number must also be included on the Attachment Face Sheet. (See details below) In order to match the supporting documentation to the appropriate claim, the Attachment Control Number in the PWK06 data element of the electronically submitted claim must match the Attachment Control Number on the corresponding Attachment Face Sheet. 8

10 Mailing Instructions: To expedite processing of such a claim: Mail the attachment the same day the claim is submitted Do not send a copy of the claim with attachment Do not send unnecessary attachments. For example, do not send a copy of the member s identification card Send a completed Attachment Face Sheet for each attachment All documentation must be received within 7 calendar days of the electronic submission. If supporting documentation is not received but is required to process the claim, Anthem Blue Cross and Blue Shield will deny the claim. For example: On 6/8, a claim is received with the PWK segment populated. On 6/15, the 7 day time period expires and the claim will be denied if the attachment has not been received. For claims in Ohio, Indiana, Kentucky, Missouri and Wisconsin, mail the Attachment Face Sheet and supporting documentation to: Anthem Blue Cross and Blue Shield PO Box Louisville, KY How to file electronic claims with adjustment information The ANSI X claim format allows you to electronically submit claims for: charges not included on a prior claim other adjustment information This electronic filing method allows you to submit an adjustment request for a previously submitted claim. We encourage you to work with your clearinghouse and/or software vendor to ensure their systems are HIPAA compliant and can accommodate electronic claims with adjustment information. Clearinghouses and software vendors should be familiar with the 837 Implementation Guides and the adjustment process. An understanding of the data entry process for your particular practice management system will be helpful in ensuring your clearinghouse can successfully transmit the data to us via the ANSI X format. 9

11 Claim adjustments claim frequency codes The 837 Professional Implementation Guide refers to the National Uniform Billing Data Element Specifications Type of Bill Position 3 (UB92, Type of Bill, third position) for explanation and usage. In the 837 formats, the codes are called claim frequency codes. Specific codes indicate that the claim is an adjustment of a previously submitted claim. The Professional 837 codes are as follows: Claim frequency code name 7 Replacement of prior claim 8 Void/cancel of prior claim Code description Use to replace an entire claim (all but identity information). We will consider the original claim null and void and replace it with the new claim. Use to entirely eliminate a previously submitted claim for a specific provider, patient, payer, insured, and statement covers period. We will void the claim from our records. When to use claim frequency codes Do use claim frequency codes for claims that were originally adjudicated (approved or denied). Do not use these codes for claims that contained errors and were not processed. How to submit claim frequency codes To submit adjustment codes on the 837 Claim (Professional), include the following information: 1. In Loop 2300, Claim Information (CLM), CLM05-3, included the appropriate Claim Frequency Code as shown in the chart below. Claim frequency code name 7 Replacement of prior claim 8 Void/cancel of prior claim Code description File electronically, as usual. File the claim in its entirety, including all ser vices for which you are requesting con sideration. File electronically, as usual. Include all charges that were on the original claim. 2. In Loop 2300, Original Reference Number, REF02 must include the original Anthem internal tracking number. This number can be found on the 835 Payment Advice (Loop 2100, CLP07, Payer Claim Control Number). Note: If the original Anthem internal tracking number (claim number) is not received or does not match the internal tracking number that was assigned to the original adjudicated claim, the adjustment request cannot be completed and may result in no action taken. 10

12 Electronic Remittance Advice (ERA) ERA overview We offer secure electronic delivery of remittance advices, which explain claims in their final status. This is an added benefit to our electronic claim submitters. If you currently receive paper remits, contact EDI Solutions today to enroll for electronic remits. Our ERA data is in the Health Insurance Portability and Accountability Act (HIPAA) compliant format, with nationally recognized HIPAA-compliant remark codes used by Medicare and other payers like Anthem. ERA advantages Administrative savings by reducing handling and processing time Eliminates paper and simplifies processes No waiting for mailed copies The file is in your electronic mailbox the same day as it is issued Provides electronic tracking of data and file storage Automates and simplifies billing to other payers (coordination of benefits) Additional ERA options increase efficiency We encourage you to contact your electronic vendor and/or clearinghouse to learn more about additional options available for ERA such as: Manual and automated posting options Single easy-to-read, printer friendly format for multiple payers Easy access and storage of payer Explanation of Benefits (EOBs) Automated coordination of benefit claims filing Capability to quickly locate documents for research and customer service Image retrieval, eliminating loss of misfiled documents Support and staff training How to enroll for ERA Download a copy from anthem.com/edi. Fax your completed form to our EDI Specialists at If you use a vendor or submit to a clearinghouse If you use an EDI vendor and/or clearinghouse, please contact their representative to discuss the electronic remittances. This will ensure that ERA enrollment procedures are followed appropriately with the vendor and with Anthem. 11

13 Electronic Funds Transfer (EFT) Electronic Funds Transfer (EFT) overview EFT is a safe, secure efficient process for directly depositing payments into your bank account. You ll have immediate access to funds because banks process transactions through the Automated Clearinghouse (ACH) network, the secure transfer system that connects all U.S. financial institutions. Providers who use EFT may notice the benefits listed below. EFT advantages Administrative savings faster access to funds may improve cash flow and help your staff save valuable time Avoid mail delays, lost checks and fraud Eliminate the cumbersome process of manual deposits Easier reconciliation of payments with bank statements Funds are transferred electronically to the providers bank usually a full day before paper copies are mailed How to enroll for EFT Complete the EFT application attached to the first paper remittance advice received each month or contact cashdisbursementseft@anthem.com. Changes after enrollment It is very important that you notify us of any changes to your EFT request form both before and after enrollment. This includes any changes to your vendor, TIN#, billing address or bank account. Complete the EFT Maintenance Request form found on our website at anthem.com/edi and fax the form and other required information to

14 ERA/EFT points of contact ERA/EFT Enrollment, Banking or vendor Changes, File Delivery and Formatting ERA Claim adjudication, payment and remark codes EFT Bank Posting, Payment Delivery/Amount Questions Anthem Delivery Schedule, File Layout and Field Definition Contact EDI Vendor For ERA contact EDI Specialists at or via at For EFT contact For ERA contact the customer service number shown on the back of the insured s identification card For EFT contact cashdisbursementseft@anthem.com Anthem HIPAA Companion Guide Available online at anthem.com/edi > Select State > documents > Anthem HIPAA Companion Guide > 835 Payment Advice Your EDI Specialists are here to help EDI Specialists are available to help you, your vendor or clearinghouse with any of the processes mentioned here. The Anthem HIPAA Companion Guide is also available online at anthem.com/edi. EDI Solutions, Anthem Blue Cross and Blue Shield 8 a.m. 5:30 p.m. Eastern time Phone: edi-mw@anthem.com Website/Live Chat: anthem.com/edi > Select State 13

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16 Anthem Blue Cross and Blue Shield is the trade name of: In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE Managed Care, Inc. (RIT), Healthy Alliance Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-hmo benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Ohio: Community Insurance Company. In Wisconsin: Blue Cross and Blue Shield of Wisconsin ( BCBSWi ) underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ( Compcare ) underwrites or administers the HMO policies; and Compcare and BCBSWi collectively underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are the registered marks of the Blue Cross and Blue Shield Association.