Preface. Summary of Changes. Table of Contents. Service Contacts. June 2015 Replaces: May 2015 S /15

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1 Preface Summary of Changes Table of Contents Service Contacts June 2015 Replaces: May 2015 S /15

2 Preface The Wellmark Provider Guide and specialty guides are billing resources for providers doing business with Wellmark Blue Cross and Blue Shield of Iowa, Wellmark Health Plan of Iowa, Inc., and Wellmark Blue Cross and Blue Shield of South Dakota. The guides are referenced in your provider agreement, and include information that applies to all benefit plans in Iowa and South Dakota unless specified within the text. Explanation of Terminology Wellmark Throughout the guides, the term Wellmark indicates Wellmark Blue Cross and Blue Shield of Iowa, Wellmark Health Plan of Iowa, Inc., and Wellmark Blue Cross and Blue Shield of South Dakota. Member Individuals with health coverage through Wellmark are referred to as members. Provider Guide Updates Wellmark s Provider guides are continually updated to bring you the most current information. The following items identify when the guide or section was last changed. The date of the most current update can be found next to the linked guide name on Wellmark.com > Provider > Communications and Resources > Provider Guides. The most current date is printed on the front cover and inside pages. The date of the version replaced is also printed on the front cover. A Summary of Changes page lists all the substantial changes made in the most current updates. The page(s) affected and a brief explanation of the change is linked from the Summary of Changes page to the change within the document. Changed text and most links appear in blue type. Printed Copies of Wellmark s Provider Guides We invite you to print Wellmark s Provider Guides from the website. Guide updates are periodically listed in the BlueInk newsletter. You will always find the current version at Wellmark.com (Provider > Communications and Resources > Provider Guides). Current Procedural Terminology (CPT) is copyright 2015 by the American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT is a trademark of the American Medical Association. Blue Cross, Blue Shield, the Cross and Shield symbols, Blue Access, Blue Advantage, BlueCard, Blue Choice, Blue Connections, Classic Blue, Blue Select, and Senior Blue are registered marks of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans. Wellmark Blue PPO SM, Wellmark Blue HMO SM, Wellmark Blue POS SM, Blue Traditions SM, SimplyBlue SM, EnhancedBlue SM, CompleteBlue SM, PremierBlue SM, and myblue HSA SM are service marks of the Blue Cross and Blue Shield Association. Wellmark is a registered mark and Alliance Select SM is a service mark of Wellmark, Inc. Wellmark Blue Cross and Blue Shield is an Independent Licensee of the Blue Cross and Blue Shield Association.

3 Claims Filing Section Summary of Changes- April, May, and June 2015 Summaries below link to the actual changes in the text. The most recent changes appear in blue. Page 5: (June) Updated the Iowa paper claims mailing address. Page 5: (June) Added the Federal Employee Program (FEP) paper claims mailing address. Page 5: (June) Added instructions for paper claim submissions to avoid delays. Pages 20-21: (April) Added information on Medicare-related claims when Wellmark is secondary. Page 26: (May) Added urgent care centers as a provider type required to submit services on the 837P/CMS Currently, urgent care services are billed to Wellmark using one of two claim forms (CMS-1500 and UB-04). Moving forward, Wellmark contracted urgent care centers will use the CMS-1500 form only using the place of service code 20. Page 59: (June) Updated the Iowa paper claims mailing address. Page 59: (June) Added the FEP paper claims mailing address. Pages 69 and 70: (June) Updated the FEP paper claims mailing address.

4 Claims Filing Table of Contents I. Introduction... 1 National Provider Identifier (NPI)... 1 Medically Necessary Services... 1 Investigational or Experimental Services... 2 Medical Necessity; Investigational or Experimental Determinations... 2 Criteria for Obtaining Patient Waivers... 2 Elements of a Valid Patient Waiver Form... 3 II. Methods of Claims Filing... 3 Electronic Format and HIPAA-AS Information... 3 Submitting Claims Electronically... 4 Electronic Provider Reports... 4 Paper... 5 III. Coding Claims... 5 ICD-9-CM... 6 CPT*... 6 HCPCS... 6 UB-04 Billing Guide... 6 Online Coding Courses... 6 Specialty Specific Provider Guides... 7 IV. Modifiers in CPT and HCPCS... 7 Modifier Review... 7 V. Wellmark s Payment Policies... 7 Payment Policy Comment Period and Notification of Change... 8 Incident To Billing... 9 Telemedicine Services... 9 Audiovisual Services Imaging/Monitoring Services VI. BlueCard Program BlueCard PPO BlueCard HMO BlueCard Managed Care/Point of Service (POS) ACA Premium Grace Period and BlueCard Members Ancillary Claims Filing Independent Clinical Lab Durable Medical Equipment Supplier/Orthotic & Prosthetic Supplier BlueCard Worldwide Program BlueCard Questions? VII. Timely Filing Timely Filing Exceptions Claims Denied Because of the Timely Filing Deadline VIII. Claims Filing Instructions Blue Cross and Blue Shield Claims Medicare-Related Claims When to File Clinical Documentation with Claims Placing the Authorization Number on a Claim Electronic Claim Form CMS-1500 Paper Claim Form UB-04 Paper Claim Form IX. Providers Required to Submit Services on the 837P/CMS X. Required Information on the 837P/CMS Bill Services Delivered on a Single Date on One Claim Practitioner Specific Billing Information... 27

5 How to Submit Late Charges on a CMS How to Submit Late Credits on a CMS CMS-1500 Claim Form Example CMS-1500 Required Field Information XI. Providers Required to Submit Services on the 837I/UB XII. Required Information on the 837I/UB Facility Specific Billing Information UB-04 Claim Form Example UB-04 Required Field Information Interim Billing How to Submit Outpatient Services Other Outpatient Billing Information Implants and Revenue Code Submitting Corrections for Facility Claims Filing Corrected Claims Late Charges Only Replacement of a Prior Claim Void/Cancel of a Prior Claim XIII. How to File Accident/Injury-Related Claims CMS-1500, UB-04, and Electronic Submission Field Requirements for Accident/Injury Claims Filing Vehicle Accident-Related Claims Filing Workers' Compensation Claims Member Questionnaires Provider Response Option How to Correct Payment on Services that were also paid by Workers Compensation or Auto Insurance XIV. Subrogation How to Refund a Payment XV. Coordination of Benefits COB and BlueCard COB and Medicare Nonduplication of Benefits Provision XVI. Double Coverage XVII. Claims Denied for Missing Information F-Code Reject Messages X-Code Reject Messages, Paper Claims Only XVIII. Verify Claim Status XIX. Claims Inquiries and Appeals Step 1: The Claims Inquiry Process Claim Corrections Which Must Be Submitted in Writing Provider Inquiry Form Provider Inquiry Form Replies Provider Inquiry Form Examples To Access Provider Inquiry Forms Modifier Adjustments How Adjustments Appear on Wellmark's Provider Reports Step 2: Provider Appeal Process XX. Claims Service Contacts Mailing Addresses and Telephone Numbers XXI. Summary... 70

6 Information in this guide applies to networks and products offered or administered by Wellmark Blue Cross and Blue Shield of Iowa, Wellmark Blue Cross and Blue Shield of South Dakota, and Wellmark Health Plan of Iowa, Inc. As individual benefit plans vary, always verify eligibility and benefits using our secure Web tools on Wellmark.com. This section of the Wellmark Provider Guide explains how to file CMS-1500 and UB-04 claims with Wellmark Blue Cross and Blue Shield of Iowa, Wellmark Blue Cross and Blue Shield of South Dakota, and Wellmark Health Plan of Iowa, Inc. It also offers guidelines about filing specific claims (e.g., BlueCard, coordination of benefits, Workers' Compensation), and identifies tools available to inquire about claim status or claim adjustments. National Provider Identifier (NPI) Wellmark only accepts a provider's 10-digit, unique National Provider Identifier (NPI) number on electronic and paper submitted claims. Claims containing an NPI and any other legacy number are rejected. Providers who have never contracted with Wellmark or been registered to file claims with us must complete the application process before they can submit claims using their NPI. To apply, visit Wellmark.com (Provider > Credentialing & Contracting), and select Practitioners or Facilities/Entities for your state. Medically Necessary Services Participating providers agree to file claims with Wellmark for services provided to members, regardless of other sources of recovery. Wellmark's payment is based on the member's eligibility, benefits, and the medical necessity of the service provided. Definition of medical necessity Medically necessary services are covered services that a physician or other health care provider, exercising prudent clinical judgment, would provide to a member for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are: a) in accordance with generally accepted standards of medical practice; b) clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the member's illness, injury or disease; and c) not primarily for the convenience of the member, physician, or other health care provider, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that member's illness, injury or disease. For these purposes, "generally accepted standards of medical practice" means standards that are based on credible scientific evidence published in peerreviewed medical literature generally recognized by the relevant medical community, physician specialty society recommendations, and the views of physicians practicing in relevant clinical areas and any other relevant factors.

7 Investigational or Experimental Services A treatment is considered investigational or experimental when it has progressed to limited human application, but has not achieved recognition as being proven effective in clinical medicine. The following criterion are used to determine investigational or experimental status: it has final approval from the appropriate governmental regulatory bodies; the scientific evidence must permit conclusions concerning its effect on health outcomes; it improves the net health outcome; it is as beneficial as any established alternatives; and the health improvement is attainable outside the investigational settings. Copies of the evaluation criteria for a specific service, supply, device, or drug are available upon request. Medical Necessity; Investigational or Experimental Determinations A Wellmark medical director, or designated health care professional, will determine whether health care services are medically necessary, or investigational or experimental. Services determined as not medically necessary, or investigational or experimental, are the liability of the provider. Criteria for Obtaining Patient Waivers Providers may seek payment from the member for experimental or investigational services, and services that do not meet Wellmark's definition of medical necessity if: the provider explains verbally and in writing to the member, prior to the signing of the waiver, that the specific services in question are experimental or investigational, or do not or may not meet Wellmark's medical necessity criteria; the provider gives a cost estimate to the member for the specific services in question; the member signs a valid waiver form before the services are performed; and the provider bills such services with the GA modifier. GA modifier indicates that the patient has signed a waiver Modifier GA Description Waiver of liability on file

8 Elements of a Valid Patient Waiver Form The patient waiver form must contain the following: Components of a valid waiver form the date the place of service the description of the service a cost estimate of the service a summary of Wellmark s medical policy or an attached copy of the policy a statement that you have met with and explained to the member that the service provided for that condition may be considered experimental, investigational, or not medically necessary by the member s health insurance policy or coverage manual and therefore, may not be covered by his or her health insurance contract benefits, and verification that the member agrees to be financially responsible for the services The GA modifier does not affect a claim s processing in any way. If the service is denied as not medically necessary, the charge will appear on your remittance and on the member s statement as provider liability. If you ve met the waiver requirements, you may bill the member for the services. The provider will not attempt to collect from members any payment reduction resulting from the provider's failure to follow Wellmark's Utilization Management procedures, such as obtaining a required prior approval or precertification. Blanket or generic waivers, intended or attempting to include any and all services which the provider may render to the member, will not be considered valid waivers with respect to nonmedically necessary, experimental, or investigational services. Please keep waivers with the member's medical record. Do not file the waiver with the claim. You can file claims with Wellmark electronically or on paper. Electronic filing is the most effective way to get claims into Wellmark's processing system, track them, and receive payment. We use a third-party clearinghouse, EC Solutions, and its electronic interchange network, INet, to receive electronic claims. While there are a number of ways to transmit electronic claims, EC Solutions is the single entry point. New format for electronic submitters Electronic Format and HIPAA AS Information The current transaction standard for electronic submission is the ANSI 837x5010 format. Providers, vendors, billing services, clearinghouses, Wellmark, and other health insurance payers must use this format for electronic transactions. For more information, go to Wellmark.com (Provider > Claims and Payment > HIPAA 5010).

9 HIPAA-AS HIPAA-AS Implementation Guide Wellmark Companion Guides The Health Insurance Portability and Accountability Act Administrative Simplification (HIPAA AS) was passed by Congress in 1996 to set standards for the electronic transmissions of health care data and to protect the privacy of individually identifiable health care information. For more information on HIPAA AS, visit The HIPAA AS Implementation Guide provides comprehensive information needed to create an ANSI 837 transaction. This guide is available for purchase online at A direct link to the 5010 guides follows: The Wellmark Companion Guides are available for use in conjunction with the HIPAA AS Implementation Guide. This guide provides specific Wellmark requirements for electronic submission. To view these guides online, visit Wellmark.com (Provider > Claims and Payment > Electronic Transaction/HIPAA Guides). Submitting Claims Electronically CMS-1500 submitters can send electronic claims to INet through the Internet using the Create & Submit a Claim tool on the Provider secure page on Wellmark.com. To gain first-time access to our online tools, apply by selecting the Register now link on Wellmark.com > Provider. Each organization must designate a main Designated Security Coordinator whom registers for secure access and assigns others within the organization access to our various applications once registration is complete. Non-participating providers must also submit the Access Agreement. Electronic Provider Reports The following INet reports are sent to electronic submitters:.txn Z16 Report Transaction Summary Report - Lists all claims accepted and rejected during HIPAA validation, including claims rejected for member eligibility reasons. Claim Error Report - Lists all claims accepted and rejected by Wellmark's system. For more information on INet reports, download the Electronic Claims Reports Manual from INet's Account Library titled REPTMAN.PDF. To learn more about how to convert your office from paper to electronic or for any electronic filing questions, contact EC Solutions at or by at ECSolutionsDSM@hp.com.

10 Most claims that once required a paper submission can now be submitted electronically. Eliminate payment delays by adding the following categories to claims filed electronically: Added categories for electronic submission Addresses for filing paper claims Non-Medicare COB claims Medicare COB claims Modifiers 24, 25, 59 Vaccines Subrogation Medicare Exhaust Dental Paper In Iowa, submit paper claims for Wellmark members to: Wellmark Blue Cross and Blue Shield of Iowa Station 1E238 PO Box 9291 Des Moines IA In South Dakota, submit paper claims for Wellmark members to: Wellmark Blue Cross and Blue Shield of South Dakota 1601 West Madison Street PO Box 5023 Sioux Falls SD Address for FEP paper claims Filing paper claims For Iowa and South Dakota FEP members, submit paper claims to: Wellmark Blue Cross and Blue Shield Station 3E463 PO Box 9291 Des Moines IA Please follow these instructions when filing paper claims to avoid delays: Submit claims on original UB-04 or CMS-1500 claim form. Do not submit copies. Submit all required claim information as indicated in this guide. Data must be typed and not handwritten. Font size should be large enough to read. Information submitted should be within the specified box. Note: The printing alignment may have to be adjusted. Paper claims must be mailed to the address specified above. All aspects of patient care, including information regarding the need for, results of, and use of information, should be legibly documented in the patient's medical record. The medical record chronologically documents the patient's medical history in sufficient detail and substantiates services as medically necessary. An important element in claims filing is the submission of current and accurate codes to reflect the services provided.

11 HIPAA-AS mandates the following code sets: 1) The International Classification of Diseases - Ninth Revision - Clinical Modification (ICD-9-CM); 2) the Physicians' Current Procedural Terminology, Fifth Edition (CPT )*; 3) the Healthcare Common Procedure Coding System (HCPCS). The following information identifies the purpose of each code set. Coding books that explain how to submit code sets are updated annually. ICD-9-CM To code diagnoses (Volumes 1 & 2) and hospital procedure codes on inpatient claims (Volume 3), use the International Classification of Diseases- 9th Revision-Clinical Modification (ICD-9-CM) developed by the Commission on Professional and Hospital Activities. ICD-9-CM Volumes 1 & 2 codes appear as three-, four- or five-digit codes, depending on the specific disease or injury being described. Volume 3 hospital inpatient procedure codes appear as twodigit codes and require a third and/or fourth digit for coding specificity. CPT* The Physicians' Current Procedural Terminology, Fifth Edition (CPT) code set is a systematic listing and coding of procedures and services performed by practitioners. CPT codes are developed by the American Medical Association (AMA). Each procedure code or service is identified with a five-digit code. To request new or revise existing procedure codes If you would like to request a new code or suggest deleting or revising an existing code, obtain and complete a form from the AMA's website at -your-practice/coding-billing-insurance/cpt/applying-cpt-codes/request-form -instructions.page or submit your request and supporting documentation to: CPT Editorial Research and Development American Medical Association 515 North State Street Chicago IL HCPCS The Healthcare Common Procedure Coding System (HCPCS) Level 2 identifies services and supplies. HCPCS Level 2 begins with letters A V and is used to bill services such as home medical equipment, ambulance, orthotics and prostheses, drug codes, and injections. UB-04 Data Specifications Manual UB-04 Billing Guide The National Uniform Billing Committee (NUBC) offers a billing guide published by the American Hospital Association called the UB-04 Data Specifications Manual. To order a copy of this guide and updates, visit and select Become a Subscriber. Online Coding Courses Wellmark offers free claims coding training courses online. To access these learning tools, visit Wellmark.com (Provider > Communication and Resources > Education). *Current Procedural Terminology 2015 American Medical Association. All Rights Reserved.

12 Specialty Specific Provider Guides Wellmark also provides free specialty specific provider guides. To view these guides online, visit Wellmark.com (Provider > Communication and Resources > Provider Guides). Modifiers submitted with an appropriate procedure code further define and/or explain a service provided. Valid modifiers and their descriptions can be found in the most current CPT or HCPCS coding book. When submitting claims, use modifiers to: identify distinct or independent services performed on the same day identify services not related to a global surgery period reflect services provided and documented in a patient's medical record Wellmark processes up to four modifiers per claim line on electronically submitted CMS-1500 claims and UB-04 outpatient facility claims. The order of the modifiers on facility outpatient claims may change based on an established priority. Modifiers that affect payment are listed first, with informational modifiers secondary. Electronic remittance advices show up to four modifiers. Paper remittance advices do not include modifiers. Inappropriate use of modifiers will cause a claim to deny. Modifier Review Wellmark biannually monitors the use of modifiers that "bypass" standard practices and policies: modifiers 24, 25, and 57 used to bypass global surgery and modifier 59 to bypass the Correct Coding Initiative. We focus educational efforts on providers who are at least two standard deviations above their specialty peer group in modifier usage. Wellmark continually reviews our medical and payment policies to determine how our practices align with national coding and billing guidelines established by the American Medical Association's (AMA) Current Procedural Terminology (CPT),* the Centers for Medicare and Medicaid Services (CMS), and specialty societies. The process of implementing, modifying, or reinforcing our current policies to be more consistent with national standards is called icap Improve the Claims Adjudication Process. Wellmark follows Medicare's National Correct Coding Initiative (NCCI) to process claims. In addition, because we serve a broader population than Medicare, we also have developed icap specialty payment policies. With security access, you can locate these policies on Wellmark's Provider Web page under Payment Policies. To gain first-time access to our secure online tools, apply by selecting the Register now link on Wellmark.com > Provider. *Current Procedural Terminology 2015 American Medical Association. All Rights Reserved.

13 Note: The institutional version of the NCCI edits was formerly implemented one calendar quarter behind the physician version. The institutional edits are being implemented concurrently with the physician version. For more information, visit the CMS website at Wellmark gives a 90-day comment period before changing payment policies Payment Policy Comment Period and Notification of Change Wellmark gives a 90-day comment period to providers prior to implementing a payment policy change. Notice of a proposed change is given by: publishing information in Wellmark's Provider newsletter, BlueInk providing a description of the new policy on our secured Provider website sending a letter to presidents of state and specialty societies affected by the policy Wellmark invites providers to share constructive feedback during the comment period. Send feedback by using the link available on our Payment Policies website or send a fax or letter to: Address for payment policy feedback icap Policy Wellmark Blue Cross and Blue Shield PO Box 9232 Des Moines IA Fax: All comments received during the 90-day period are reviewed. Final policies are posted on our website at Wellmark.com (Providers > Claims and Payments). icap applies to CMS-1500 and UB-04 outpatient facility claims The icap improvement process applies to CMS-1500 claims and UB-04 outpatient facility services claims and adjustments (electronic and paper). icap policies also apply to BlueCard Host professional and outpatient facility claims, Federal Employee Program (FEP) professional and outpatient facility claims, and home medical equipment (HME) and ambulance claims. Claims where Wellmark is the secondary insurer are processed through the icap system. BlueCard professional and outpatient facility host claims (claims for members of Blue Plans other than Wellmark) are also subject to icap edits. icap currently does not apply to the following types of claims: Medicare supplement BlueCard Home Web address for CCI information Web address for Medicare s Physician Fee Schedule For information on Medicare's National Correct Coding Initiative, visit For information on the Medicare Physician Fee Schedule Database, visit Specific information on how icap impacts outpatient services can be found in the Outpatient Services Provider Guide on Wellmark.com (Provider > Communications and Resources > Provider Guides).

14 Definition Supervising physician availability Using supervising physician s NPI Using midlevel practitioner s NPI When services do not meet incident to rules Incident To Billing Incident to means services that are part of the patient s normal course of treatment, during which a physician personally performs an initial service and remains actively involved in the course of treatment. The physician does not have to be physically present in the patient s treatment room while all services are provided, but the physician must provide direct supervision: that is, he or she must be present in the office suite to render assistance, if necessary. Many midlevel practitioners are providing care under a physician s supervision including those with a provisional license. Claims for those services, as long as the incident to rules are met, may be submitted using the physician s NPI. However, if the midlevel practitioner has enrolled and completed credentialing with Wellmark, those services should not be billed as incident to. Midlevel practitioners who have enrolled with Wellmark should submit claims for all services performed using their own NPI. Midlevel practitioners providing services that do not meet the incident to rules should enroll with Wellmark and bill for services under their own NPI. Office personnel (i.e., RN, LPN) that do not meet the definition of a midlevel practitioner should always bill services under their supervising physician s NPI number. Coverage for therapy services billed by a physician is dependent on whether the service meets the standards and conditions, other than licensing, applicable to a therapist. Services for physical therapy assistants and occupational therapy assistants may be billed under the supervision of a licensed therapist or physician. Definition of telemedicine services Telemedicine encounter Telemedicine Services Telemedicine usually involves physicians using interactive audio/video and/or electronic images to treat patients. Interactive audio/video allows medical specialists to directly communicate with their patients who are in another location, using television monitors and specially adapted equipment. Physicians may send electronic images such as pictures, x-rays, and other patient information directly to the computer of a specialist. After reviewing that information, the specialist sends the diagnosis back to the local doctor, who treats the patients and provides follow-up care. Telemedicine Exemption From Face-to-Face Meeting Requirement The telemedicine encounter must meet the following criteria, which are either required by CMS (Centers for Medicare and Medicaid Services) or recommended by the ATA (American Telemedicine Association).

15 Standards of care Requirements for originating site personnel Medical record required At the distant site: A practitioner performs an exam of a patient at a separate, remote originating site location. The information available to the distant site physician for the medical problem to be addressed is: ~ equivalent in scope and quality to what would be obtained with an original or follow-up face-to-face encounter ~ meets all applicable standards of care for that medical problem, including: documentation of a history a physical exam ordering diagnostic tests making a diagnosis initiating a treatment plan with discussion and informed consent At the originating site: An individual with approved clinical training background (e.g., PA, ARNP, RN, etc.) and trained in the use of the equipment: ~ presents the patient ~ manages cameras ~ performs any physical activities to successfully complete the exam A medical record, preferably a shared Electronic Medical Record: must be kept must be accessible at both distant and originating sites must be full and complete and meet the standards as a valid medical record Follow-up care: must be equivalent to that available to face-to-face patients Equipment and technical standards Physicians providing telemedicine medical care must comply with all relevant safety laws, regulations, and codes for technology and technical safety. Organizations shall meet required published technical standards for safety and efficacy for devices that interact with patients or are integral to the diagnostic capabilities of the practitioner when and where applicable. Telemedicine technology must be sufficient to provide the same information to the provider as if the exam had been performed face-toface. Telemedicine encounters must comply with HIPAA (Health Insurance Portability and Accountability Act of 1996) security measures to ensure that all patient communications and records are secure and remain confidential

16 Technology guidelines Audio and video equipment must permit interactive, real-time communications. Video screens must be of sufficient size, quality and resolution for the size and layout of the room at the originating site. Video cameras must provide high quality resolution and clarity. Audio equipment must provide clear and audible sound. A network connection must have sufficient bandwidth so that no audio or video latency, jittering, or artifacting exists. Lighting must be sufficient for the size and layout of the room at the originating site. Technology must be HIPAA compliant. CMS authorization CMS qualified originating sites Audiovisual Services The Centers for Medicare and Medicaid Services (CMS) have authorized specific originating sites as qualified for furnishing a telehealth service. When reporting modifier GT, the physician or qualified health care professional is certifying that services are rendered to a patient located in a qualified originating site via an interactive audio visual telecommunications system. Originating sites authorized as qualified by CMS are listed below: The office of a physician or practitioner A hospital (inpatient or outpatient) A critical access hospital (CAH) A hospital-based or critical access hospital-based renal dialysis center (including satellites); A skilled nursing facility (SNF) A community mental health center (CMHC) Telemedicine services may be provided by: Eligible Providers A physician A nurse practitioner A physician s assistant A nurse midwife A clinical nurse specialist A clinical psychologist A clinical social worker A registered dietitian or nutrition professional A licensed mental health counselor Services provided by telemedicine may include the following: Authorized services Office or other outpatient visits Individual psychotherapy Pharmacologic management Psychiatric diagnostic interview examination End-stage renal disease related services Neurobehavioral status exam Individual medical nutrition therapy performed by a dietetic professional under the supervision of a primary care provider

17 Modifier GT The use of modifier GT indicates a telehealth service was performed via interactive audiovisual telecommunications system and the patient was present at a qualified originating site. Wellmark will reimburse for telehealth services recognized by CMS when reported with modifier GT (Interactive Telecommunications). Any other service reported with modifier GT that is not recognized by CMS will not be reimbursed. Do not submit modifier GQ Nonreimbursable codes Payable with GT modifier Wellmark will not reimburse telehealth services submitted with modifier GQ (Asynchronous Telecommunications), because these services do not include direct, in-person patient contact. Wellmark follows CMS guidelines and does not reimburse for the following services, because they do not involve direct, in-person patient contact: telephone charges submitted with CPT codes *, or CPT codes and (Online Medical Evaluation) LIST OF SERVICES PAYABLE WITH A GT MODIFIER * G0108-G0109 G0270 G0396-G0397 G0420-G0421 G0436-G0437 G0442-G0447 If your facility is an originating site for a patient, i.e., the member's physical location at the time of service, submit a claim to Wellmark using HCPCS code Q3014 (Telehealth originating site facility fee). The provider at the distant site will submit a claim to the local Blue Plan for the service provided. Example: Your hospital has the equipment to be an originating site. A Wellmark member or a member of another Blue Plan comes to your hospital for an audiovisual face-to-face appointment with a practitioner in Ohio. Your hospital would bill Wellmark for the originating service, using Q3014. The Ohio practitioner would bill the Ohio Blue Plan for the professional services. *Current Procedural Terminology 2015 American Medical Association. All Rights Reserved.

18 Site of Origin (Member s physical location at time of service) Wellmark Plan area Wellmark Plan area INTERACTIVE AUDIOVISUAL SERVICES Distant Site (Provider location) Wellmark Plan area Other Blue Plan area Plan Billed Site of Origin Distant Site Site of Origin Wellmark Wellmark Q3014 Wellmark Other Blue Plan Q3014 Services Billed Distant Site Professional CPT* + GT modifier Professional CPT + GT modifier Telemedicine services performed by out-of-state providers Telemedicine services performed by in-state providers Imaging/Monitoring Services If your practice or facility uses out-of-state providers for imaging and monitoring telemedicine services, bill Wellmark the global service (i.e., both the professional and the technical component). Wellmark will reimburse you for the services at your Wellmark contracted rate. As the entity that contracts with the out-of-state provider, it is your responsibility to pay the out-of-state provider for the telemedicine services. Blue Cross and Blue Shield licensing rules state that Wellmark cannot contract with providers based outside our service area, except for durable medical equipment suppliers, clinical laboratories, and specialty pharmacies. If you contract with other Iowa or South Dakota providers for imaging and monitoring telemedicine services: 1) You may each bill for the service you provided professional or technical as long as each of you participates in Wellmark's networks, or 2) You may bill for both the technical and professional service, depending on your contractual arrangement with the telemedicine provider, as long as you perform the technical service and the other provider has agreed not to bill Wellmark direct. Technical Site (Member s physical location at time of service) Wellmark Plan area Wellmark Plan area IMAGING/MONITORING SERVICES Professional Site (Provider location) Wellmark Plan area Other Blue Plan area Technical Site Plan billed Professional Site Services Billed Global or Split Bill (with TC or 26* modifier, as appropriate) Wellmark Wellmark Either global or split Wellmark Wellmark Global bill from par physicians; facilities bill an institutional claim for technical component and a professional claim for professional component *Current Procedural Terminology 2015 American Medical Association. All Rights Reserved.

19 Note: Wellmark Health Plan of Iowa is able to contract with providers in contiguous counties. An out-of-state telemedicine provider who contracts with Wellmark Health Plan of Iowa may bill for telemedicine services provided for members covered by the following products: TRADITIONAL HMO PRODUCTS WELLMARKBLUE HMO SM WELLMARKBLUE POS SM Blue Access SimplyBlue SM 4750 SimplyBlue SM 5000 Blue Advantage SimplyBlue Max SM 6250 CompleteBlue SM 1500 Blue Choice CompleteBlue SM 2000A EnhancedBlue SM 1250 hawk-i Blue Access myblue HSA SM Silver 2000 EnhancedBlue SM 500 PremierBlue SM 500A The BlueCard Program links participating providers and the independent Blue Cross and Blue Shield Plans across the country and around the world through an electronic network for claims processing and payment. The alpha prefix in front of a member's identification (ID) number is what drives the BlueCard Program. BlueCard logo Claims filing instructions To help you identify members who participate in the BlueCard Program, you will see a suitcase logo on their ID card. This logo indicates that members have health coverage outside of their Blue Cross and Blue Shield Plan's service area. The BlueCard Program allows you to file all Blue Cross and Blue Shield members' claims with Wellmark for processing. Note to providers in border counties: Providers in counties along Iowa s borders may also be able to contract with the Blue Plan in the adjacent state. If you contract with the Plan under which your patient is covered, please file the claim direct with that Plan. Providers in counties adjacent to Iowa may contract with Wellmark Health Plan of Iowa (WHPI) for our HMO and POS products only: Blue Access, Blue Advantage, and Blue Choice, as well as the new ACA products whose ID cards show the Wellmark Blue HMO SM or the Wellmark Blue POS SM networks. If you are a WHPI contracting provider in a county outside Iowa, please file claims for members covered by these products only with Wellmark. Claims for services to Wellmark members covered by our PPO, indemnity, and senior products must be processed through BlueCard; i.e., filed with the Blue Plan in the state where the services were provided. Ancillary services BlueCard claims filing guidelines for ancillary service providers such as independent clinical labs, durable medical equipment suppliers, and orthotic & prosthetic suppliers are outlined later in this section.

20 If for some reason a claim cannot be processed through the BlueCard Program, we will electronically forward the claim to the member's Home Plan. If more information is needed to process the claim, the member's Home Plan will contact Wellmark. We will then research and forward the requested information to the Home Plan. File BlueCard claims with Wellmark When ID card has no alpha prefix BlueCard Program procedures If the member's Home Plan returns a claim to you for more information, please provide the missing details and refile the claim with Wellmark. If the member's Home Plan requests medical records (or other information) to finish processing, but does not return the claim, please send the requested information to Wellmark. We will forward the information to the Home Plan using the appropriate address. Note: Please do not send information directly to the Home Plan. The only time you would not send a claim directly to Wellmark is if the member carries an ID card without an alpha prefix. For ID cards without alpha prefixes, file the claim with the Blue Plan indicated on the back of the ID card. Here's how the BlueCard Program works: File the BlueCard member's claim with Wellmark. Wellmark electronically routes the claim to the member's Home Plan. The member's Home Plan processes the claim and approves payment. Wellmark pays the participating provider while the member's Plan sends an Explanation of Benefits form to the member. Determine a BlueCard member's managed care requirements (e.g., precertification, emergency admission) at Wellmark.com (Provider > Medical Policies and Authorizations > Medical Policy and Pre-Service Review for Out-of-Area Members). The member or the provider may also call the Home Blue Cross and Blue Shield Plan for this information. Out-of-state Blue Plan PPO Coverage BlueCard PPO BlueCard PPO allows Blue Cross and Blue Shield members in Iowa or South Dakota who have preferred provider organization (PPO) coverage from another Blue Plan to receive the same benefits and savings they would in their home state. The only thing the member needs to do is receive services from a provider in the Wellmark Blue PPO SM network. The only thing you need to do is file the claim with Wellmark for processing. The PPO suitcase on the member's card helps you recognize BlueCard PPO members. File BlueCard PPO claims before collecting coinsurance Note to PPO Practitioners: Coinsurance for members with BlueCard PPO coverage is calculated off the lesser of charge or Wellmark's maximum allowable fee (MAF). File BlueCard PPO members' claims with Wellmark for processing before you collect any amount from the member. Settlement will be sent to your office.

21 BlueCard HMO guest membership BlueCard POS UPS BlueCard HMO BlueCard HMO allows Blue Cross and Blue Shield members to have guest memberships while temporarily residing outside their Home Plan HMO's service area. If patients enrolled in any of Wellmark Health Plan of Iowa's coverages (Blue Access and Blue Advantage, as well as the new ACA products with ID cards showing the Wellmark Blue HMO SM network) need out-of-state services for an extended period of time, advise them to call to enroll in guest membership. BlueCard Managed Care/Point of Service (POS) Patients with Blue Cross and Blue Shield POS coverage who live in Iowa, outside their Home Plan's service area, can participate in the BlueCard Managed Care/POS Program. Members with point-of-service coverage from other Blue Plans should access care from providers in the Wellmark Blue POS SM network to receive the highest benefit levels. At the time of enrollment, members must select a primary care physician from this network to coordinate their health care needs. UPS is currently the only group enrolled in the BlueCard Managed Care/POS Program: Alpha Prefix UPP Company Name United Parcel Service File claims for BlueCard Managed Care/POS members with Wellmark Blue Cross and Blue Shield of Iowa for processing. ACA Premium Grace Period and BlueCard Members The Affordable Care Act provides special protections to members who purchase insurance policies on the exchange or health insurance marketplace. Individuals who don t pay their monthly insurance premiums will have a 90-day grace period before their coverage is cancelled. Since Wellmark is not participating on the exchange or health insurance marketplace in 2014 or 2015, Wellmark members will not be impacted in 2014 or However, you may see a few BlueCard members covered by other Blue Plans for whom this regulation will apply. If an insured individual misses a premium payment, federal regulations require insurers to pay for services rendered the first 30 days after the payment lapse. Wellmark will identify the Blue Plan member and send a letter to the provider on behalf of the Home Plan, indicating claims for the insured are pending due to a lapse in payment. If, after 90 days, payment still has not been received, Wellmark will deny the pending claims for the last 60 days. Since there is no insurance coverage, the provider may collect the appropriate claim amount directly from the patient. Providers can confirm claim receipt and status simply and quickly with the Check a Claim tool on the Provider secure page on Wellmark.com.

22 Ancillary Claims Filing BlueCard claims filing guidelines have been clarified for Independent Clinical Labs and Durable Medical Equipment Suppliers (DME). Claims performed by these providers should be submitted to the local plan. The local plan is defined differently depending on the provider type. See explanation and examples below: Local Plan defined for independent clinical labs Independent Clinical Lab The local Plan is defined as the Plan in whose service area the specimen was drawn. Independent Clinical Lab claims require that the NPI of the provider who performed the draw be included in Field 17b on the CMS On the 873 Professional Electronic Submission, enter the NPI in Loop 2310A (claim level). Example: The patient sees his PCP in Iowa and has a specimen taken. The specimen is sent to an independent clinical lab in North Carolina for analysis. The claim for the analysis of the specimen should be submitted to Wellmark. The NPI of the physician who performed the specimen draw should appear in Field 17b of the CMS The claim will be settled according to the contracting relationship between the submitting provider and Wellmark. Local Plan defined for DME, O&P suppliers Durable Medical Equipment Supplier/Orthotic & Prosthetic Supplier The local Plan is defined as the Plan to whose service area the equipment was shipped, or in which it was purchased at a retail store. The address to which the equipment was shipped should appear in Field 5 on the CMS-1500, or in Loop 2010CA on the 837 Professional Electronic Submission. Example: A patient residing in South Dakota receives medical supplies from a mail order DME supplier based in Ohio. The DME supplier should submit this claim to Wellmark for processing. The claim will be settled according to the contracting relationship between the Ohio DME supplier and Wellmark. In-network and out-ofnetwork claims Contact Blue Plans in states where you provide services If the lab or DME participates in Wellmark s networks, the claim will be settled as in-network, and if the lab or DME does not participate, the claim will be settled as out-of-network. In-network claims are settled directly with the provider, while out-of-network claims are settled with the member. If you currently provide services in other states, we recommend contacting the Blue Plans in those states regarding enrollment and contracting options for processing claims for durable medical equipment, orthotics and prostheses, and independent clinical laboratory services. Your contract with Wellmark does not make you a participating provider with any other Blue Cross and Blue Shield Plan.

23 How to file claims for BCBS international members BlueCard Worldwide Program Through the BlueCard Worldwide Program, you can submit claims for international Blue Cross Blue Shield (BCBS) Plan members direct to Wellmark for processing. Identification cards for international BCBS members carry the Blue Cross and Blue Shield names and logo, as well as the alpha prefix before the member's identification number. Follow these steps to file claims for international BCBS members: Step: 1 Step: 2 Step: 3 With the international BCBS Plan member s ID card in hand, call the toll-free BlueCard Eligibility number at BLUE (2583) to verify eligibility and coverage. Provide the customer service associate (CSA) with the member s alpha prefix, and the CSA will route your call to the member s BCBS Plan to verify eligibility and coverage information. Once the member receives care, collect the same out-of-pocket expenses (deductible, copayment, coinsurance, noncovered services) as you currently do for domestic BCBS members. Then submit the claim with the member s alpha prefix and identification number to Wellmark. BlueCard Questions? Information Iowa South Dakota BlueCard Program Web page Out-of-State Blue Plans Eligibility Wellmark.com (Provider > BlueCard) Visit the secure Provider pages on Wellmark.com. Under Provider Tools, select Check Member Information. or call Out-of-State Blue Plans Claim Status or Payment Information Visit the secure Provider pages on Wellmark.com. Under Provider Tools, select Check a Claim. or call If you have questions regarding coordination of benefits for BlueCard members, turn to the Coordination of Benefits section in this guide. To gain first-time access to our secure online tools, apply by selecting the Register now link on Wellmark.com > Provider.

24 Wellmark s timely filing guideline Coordination of benefits claims BlueCard timely filing requirements Effective January 1, 2015, to be considered for reimbursement, most Wellmark claims must be received within 180 days from the date of service or the discharge date. For dates of service prior to January 1, 2015, the claims must be received within 365 days from the date of service or the discharge date. The 180 day timely filing guideline will also apply to COB claims. When Wellmark is the secondary payer, claims must be filed within 180 days from the issue date of the primary payer's Explanation of Benefits (EOB). If the primary payer does not issue an EOB, we will use the date on the provider's remittance advice. BlueCard claims must meet both the member's Home Plan's and Wellmark's timely filing requirements to be eligible for benefit consideration. For example: - If a member with out-of-state coverage has a timely filing guideline shorter than Wellmark's 180-day requirement, the claim will be denied as member liability. A Wellmark participating provider may bill the member in this instance. - If a claim is within the member's timely filing timeline, but exceeds Wellmark's 180-day requirement, the claim will be denied as provider liability. A Wellmark participating provider cannot bill the member in this instance. Exceptions to the timely filing guideline Medicaid exception for facilities Timely Filing Exceptions The following are exceptions to the 180-day guideline: Medicare supplement (e.g., MedicareBlue Supplement SM and Senior Blue ) claims will process as long as the claim was filed within Medicare's time frame. Medicaid exception: Since Medicaid is always the payer of last resort, Iowa Medicaid will return or disallow claims from facilities if it is determined that Wellmark is primary. Wellmark will make exceptions to the timely filing deadlines when: - the facility did not know the patient had Wellmark coverage - the facility filed the claim with Medicaid within 365 days of the date of service - the claim was disallowed within 36 months of the date of service - the facility then files the claim with Wellmark Claims filed outside Wellmark's timely filing guidelines will automatically be denied. For the claim to be considered, file a Provider Inquiry including the following: - the reason the claim was not filed with Wellmark initially - the Medicaid disallowance letter

25 Check for Wellmark coverage first to avoid extra steps Note: Avoiding these steps is within your control. We recommend that when a member presents only a Medicaid card, providers check for Wellmark coverage on the secure Provider page of Wellmark.com and file with Wellmark first when appropriate. You may search for coverage using the member's name; the ID card is not required. Claims Denied Because of the Timely Filing Deadline If you, as a participating provider, fail to file claims within the 180-day parameter, you cannot bill members for covered services associated with those claims. Whether or not you can collect payment from a BlueCard member depends on if the claim denies as member or provider liability (see examples above). We will consider circumstances beyond a provider's control that resulted in delayed submission of claims on a case-by-case basis. Your request to review claims which were denied because of failure to meet the timely filing deadline should include documentation that supports your particular situation, and be submitted on the Provider Inquiry form. Filing instructions for Blue Cross and Blue Shield claims Filing instructions for Medicare-related claims Allow 30 days from MRN date for claims to cross over from Medicare Blue Cross and Blue Shield Claims Submit all Blue Cross and Blue Shield claims to Wellmark for processing. If claims cannot be processed through the BlueCard Program, Wellmark will either physically or electronically forward claims to each member's Home Plan and send you written notification that they have been forwarded. For more information, go to the BlueCard Program section in this guide. Medicare-Related Claims When you file claims with Medicare involvement, always file the claim with Medicare first. In most cases, Medicare will automatically forward the claim to us for processing. If a Medicare-related claim is not automatically forwarded to us, you may submit primary payment information to us electronically, or by submitting a paper form. Effective October 13, 2013, providers must wait 30 calendar days from the date of the Medicare Remittance Notice (MRN) before submitting the claim to the local Plan. This includes Medicare primary claims and those with Medicare exhaust services. Medicare primary claims received before the 30 calendar days are up will be rejected. The 30-day time frame is designed to avoid duplicate processing and payment inconsistencies. For Medicare-related claims : N89 or MA18 remark codes Wellmark will look for remittance advice remark codes N89 or MA18 on incoming provider submitted Medicare COB claims. The presence of one of these codes indicates the claim was crossed over to the secondary payer (Wellmark).

26 Date is less than 30 days from receipt date Date is greater than 30 days from receipt date No N89 or MA18 remark codes When N89 or MA18 is present, Wellmark will review the Medicare Adjudication date. When this date is not 30 days or more in the past, the claim will be rejected for MEDICARE REMIT DTE < 30 DAYS BEFORE RECEIPT DTE. When N89 or MA18 is present, and the date is more than 30 days in the past, the claim will continue to process through the Wellmark system and will not reject for MEDICARE REMIT DTE < 30 DAYS BEFORE RECEIPT DTE. When N89 or MA18 is not present, Wellmark will process the claim through the Wellmark system and will not reject for MEDICARE REMIT DTE < 30 DAYS BEFORE RECEIPT DTE. FEP exception Filing Medicare COB claims electronically Exempt from this requirement are claims for members with coverage through the Federal Employee Program (FEP). FEP claims may be submitted to the plan within 15 days of the date of service. To submit Medicare COB claims electronically, follow the steps below: 1. When Medicare Part A (Institutional) is the primary payer and the claim is Inpatient, Medicare provides payment information at the claim level. Medicare payment information is to be created at the claim level when submitting these claims to Wellmark. 2. When Medicare Part A (Institutional) is the primary payer and the claim is Outpatient, Medicare provides payment information at the header and line level. Medicare payment information is to be created at the header and line level when submitting these claims to Wellmark. 3. When Medicare Part B (Professional) is the primary payer, Medicare provides payment information at the header and line level. Medicare payment information is to be created at the header and line level when submitting these claims to Wellmark. Note: When submitting claims to Wellmark, place Medicare COB claims in a separate file from other 837 formatted claims. A special Receiver ID (88848MC) is to be used in the ISA08 and GS03 elements. If Medicare COB claims are not submitted using this Receiver ID, the claim will be rejected and not allowed into Wellmark's system. When claims that are not Medicare COB are submitted using the new Receiver ID, the claims will be rejected out of the Wellmark system. For additional information regarding the Medicare crossover process and examples for Wellmark specific requirements regarding various 837 loops and segments for Medicare COB claims, refer to the 837 COB HIPAA AS Wellmark Companion Guides at Wellmark.com (Provider > Claims and Payment > Electronic Transaction/HIPAA Guides).

27 Faxing a Medicarerelated claim To fax a claim, please follow these steps: 1) Fax a photocopy of the front and back of the member's current Medicare ID card to Wellmark. IA Fax: ; SD Fax: ) Include the member's Wellmark ID number along with the copy of the member's Medicare ID card. Filing Medicarerelated paper claims Please follow these instructions when filing Medicare-related paper claims: Practitioners (CMS-1500 Submitters) Submit a completed CMS-1500 and a detailed Medicare Remittance Notice (MRN). All services listed on the CMS-1500 must be on the MRN. 1 Facilities (UB-04 Submitters) Submit a completed UB-04 and a detailed MRN that lists all services identified on the UB-04 claim form. 1 Total charges on the UB-04 must match the Total/Reported charges on the MRN. Noncovered charges billed to Wellmark must have Medicare codes (explanation of denials) in order for us to process the claim correctly. Enter noncovered individual charges in form locator 48. Note: Inpatient claims do not require a detailed MRN. MRN required details To avoid denials, the following details MUST be submitted on an itemized MRN along with the original paper claim submission: Name of Patient Date of service Total billed charges (not balance due) Billed Procedure code(s) and modifier(s) Medicare approved amounts at header and line level Medicare adjudication date Medicare deductible 2 at header and line level Medicare coinsurance at header and line level Medicare non-covered and/or denied charges at header and line level Medicare new claim adjustment reason code (CARC)/contractual obligation amounts and reason codes at header and line level. If multiple CARC codes, each code requires an amount. Patient responsibility amounts and reason codes Contact information Medicare Contacts To obtain a copy of the MRN, providers can call Medicare Provider Service at or log in to C-SNAP found on the WPS Medicare Web page. 1 We must receive both forms or the claim will be returned. We do not accept Medicare Summary Reports. 2 The Medicare Part B deductible for 2015 can never exceed $147. If an amount higher than the Part B deductible is listed on the MRN, the claim will be returned.

28 When to File Clinical Documentation with Claims The 22* modifier appended to the surgery code indicates that the work required to provide a service was substantially greater than typically required. When you submit this modifier, always attach to the claim additional documentation (e.g., an operative report) that supports the need for the additional work. After Wellmark reviews the documentation submitted with the claim, increased payment beyond the usual amount for that procedure may be made if our medical staff agrees that it is warranted. Wellmark may require submission of clinical records before or after payment of claims beyond the situation noted above to investigate potential fraud, abuse, or other inappropriate billing practices, for as long as there is a reasonable basis that such investigation is warranted. Types of clinical documentation include, but are not limited to: operative notes MD office notes facility notes facility/md notes lab results anesthesia notes and time radiology interpretation and report Types of clinical documentation Placing the Authorization Number on a Claim Providers should include the prior approval authorization number on all claims related to the specific procedure or service requiring prior approval. Providers are also encouraged to include the authorization number for other authorized services. 837 Electronic Claim Form Please place the authorization number in Loop 2300 of the 837 Electronic Claim Form. 837 Name Loop Segment Min Prior Authorization or Referral Number 837 Max Entry Max Format Requirements Notes 2300 REF ID Not required 1 REF01- G1 1 This is a "not required" field when submitting the 837, but Wellmark requires it to ensure proper payment. Institutional claims can have one authorization number and one referral number at the claim level. If the primary reason for the admission is for a procedure that requires prior approval, submit that authorization number on the claim; otherwise, submit the inpatient notification/precertification number. Professional claims can have one authorization number at the claim level (Loop 2300) as well as one authorization number at each line level (Loop 2400), if required. In the REF-Prior Authorization segment, the G1 qualifier is used at the claim and line level for the authorization number; the 9F qualifier is used at the claim and line level for the referral number. *Current Procedural Terminology 2015 American Medical Association. All Rights Reserved.

29 CMS-1500 Paper Claim Form Please place the authorization number in Field 23, Prior Authorization Number, of the CMS Note: Field 23 is also used by ambulance service providers to report the ZIP code only of the pick-up location, as there is no field on the paper form to accommodate the full address. Please separate numbers with a semicolon. UB-04 Paper Claim Form Please place the authorization number in Form Locator 63, Treatment Authorization Codes, of the UB-04. Place the procedure authorization number on line A and the facility authorization number on line B.

30 Providers listed in the chart below and on the next page are expected to submit services electronically on the 837P, or on the CMS-1500 claim form if submitting on paper. 837P/CMS-1500 Submitters by Provider Type Advanced Registered Nurse Practitioner Certified Registered Nurse Anesthetist Certified Nurse Practitioner Certified Nurse Midwife Certified Clinical Nurse Specialist Ambulance Audiologist Chiropractor Community Mental Health Centers Dentist Durable Medical Equipment Home Medical Equipment Services & Supplies Freestanding Magnetic Resonance Imaging Facility Freestanding Radiology Center FS CT Scan Center FS Mammography Center FS PET Scan Center FS Portable X-Ray FS Radiation Oncology Center FS Ultrasound Center Home Infusion Therapy Independent Clinical Laboratory (ARNP) (CRNA) (CNP) (CNM) (CNS) (CMHC) (DME) (HMESS) Notes Hospital-based ambulance services are billed by the hospital. May bill for dental services related to accidental injuries involving the teeth up to one year after the occurrence. Hospital-based services are submitted by the hospital. Hospital-based services are submitted by the hospital. Cont. on next page.

31 Providers required to file on the 837P or the CMS-1500, cont. 837P/CMS-1500 Submitters by Provider Type Notes Licensed Marital and Family Therapist (LMFT) Mental Health Counselor Licensed Mental Health Counselor (LMHC) (IA only) Licensed Professional Counselor Mental Health (SD only) (LPC-MH) Occupational Therapist (OT) Optometrist (OD) Oral Pathologist Oral Surgeon Orthotic & Prosthetic Supplier Physical Therapist (PT) Physician (MD, DO) Physician Assistant (PA) Psychologist (PhD, PsyD, EdD) In Iowa, a psychologist must also have an Iowa Health Services Provider number, and/or be on the national registry. Podiatrist (DPM) Public Health Agency (PHA) Qualified Mental Health Professional (SD only) (QMHP) Social Worker Certified Social Worker - Private Independent Practice (SD only) (CSW-PIP) Licensed Independent Social Worker (IA only) (LISW) Speech Language Pathologist (SLP) Sleep Center Hospital-based services are billed by the hospital. Urgent Care Centers Use the place of service code 20. Visiting Nurse Association (VNA) Accepted January 1, 2014 Same date of service, same claim Attach additional form when needed The Centers for Medicare and Medicaid Services (CMS) has created a new CMS-1500 claim form, version 02/12. The form is available through a forms vendor. Following Medicare's lead, Wellmark began accepting the new form January 1, Wellmark will continue to allow submissions of the CMS-1500 form (version 05/05) until further notice. Wellmark does, however, encourage you to begin using the new version (02/12) as soon as possible. The CMS-1500 has six claim lines. Avoid processing delays and potential errors by billing all services delivered on a single date of service on the same claim. Do not use the shaded lines on the form as additional claim lines. If a claim requires more than six lines, enter the word "continued" or "Cont." in the Total Charge field (FL 28) and attach another claim form.

32 Bill Services Delivered on a Single Date on One Claim Splitting services provided on the same date of service into multiple claims can result in incorrect denials or processing errors. Examples: When the same procedure is billed on different claims on the same date of service and by the same provider, the second claim will deny as duplicate services. When multiple surgeries performed on the same day are billed on different claims, the procedure code with the higher Wellmark maximum allowable fee (MAF) could be discounted according to multiple surgery rules. When multiple surgeries are billed on the same claim, the code with the higher MAF will not be discounted. When add-on codes performed on the same day are billed on different claims, the claim for the add-on code may be denied, as the primary procedure code cannot be found for correct claims processing. Page 29 shows an example of the new CMS-1500, followed by a chart that identifies the required fields you must complete in order for Wellmark to process claims accurately. The numbers to the left of the chart correspond to those on the claim form. If one or more of the "required" fields are left blank or are incomplete, the claim will be rejected. The Provider Claim Remittance (PCR) will indicate one of the following reasons if a claim is rejected for missing or invalid information: member information provider information diagnosis or procedure code alpha prefix patient relationship to insured information on the claim (general) Submit the updated claim as a new claim. Do not attach it to a Provider Inquiry form. For more information, see the Claims Denied for Missing Information section in this guide. CMS-1500 required fields for claim submission The CMS-1500 Required Field Information chart provides basic filing instructions you need to submit services for payment. For detailed coding instructions, refer to the 1500 Health Insurance Claim Form Reference Instruction Manual found at To ensure accurate diagnosis and procedure coding, use the code sets described in that manual. NPI Note: To avoid claim rejections, notify Wellmark of your NPI number prior to using it on a claim. Specialty-specific Provider Guides for practitioners Practitioner Specific Billing Information Wellmark also offers specialty-specific Provider Guides to help practitioners code and bill specific services (e.g., physical medicine, eye care, home medical equipment). To view these Provider Guides online, go to Wellmark.com (Provider > Communication and Resources > Provider Guides).

33 How to Submit Late Charges on a CMS-1500 Wellmark refers to services submitted at a later date than the first claim received for a particular date of service from the same provider as "late charges." To submit late charges, send us a new claim for the additional services. Do not submit the original claim with the additional charges added to it. How to Submit Late Credits on a CMS-1500 If your office determines that charges submitted to Wellmark were billed in error, please submit a copy of the original claim along with a corrected claim (noting the changes) to credit the member's account. Submit late charges and late credits to: Iowa Claims Inquiry Resolution Team Mail Station 5E393 Wellmark Blue Cross and Blue Shield PO Box 9232 Des Moines IA South Dakota Provider Service Center Mail Station 347 Wellmark Blue Cross and Blue Shield 1601 W Madison Street Sioux Falls SD Wellmark secondary payer on late charges or late credits If Wellmark is the secondary payer on late charges or late credits, please include a copy of the corrected Explanation of Benefits from the primary carrier.

34 Required Required Required Valid alpha prefix and ID number required. Required Required if different from Insured s address Required Enter the complete address of the policyholder Complete blocks 9a & 9d Required if block 11d is checked yes. Required Required Referring physician name and NPI required. Required At least 3-digit, valid ICD-9 code(s) are required. Conditionally Required. Required for electronic. Required A compatible place of service value is required for each service. Submit a valid CPT or HCPCS code. If a modifier is used, it must be valid for the procedure performed. Required for Medicare-related claims. Submit a charge for each procedure performed (even if the charge is $0.00). Indicate the number of services based on the time period or the amount designated by the code. Wellmark required individual NPI provider numbers when an individual provider is part of a group. This box is to be left blank if you are not part of a group. Required Required for electronic. Required Required Conditionally Required. Enter the practitioner s/supplier s billing name, address, phone number and NPI.

35 CMS-1500 Required Field Information Field No. Field Name Explanation 1a Insured s ID Number Enter the policyholder s alpha prefix and ID number as shown on his/her identification card. 2 Patient s Name Enter the patient s full given name (no nicknames). 3 Patient s Date of Birth Enter the correct date of birth (MM/DD/CCYY) and sex of the patient. 4 Insured s Name Enter the policyholder s name. 5 Patient s Address Required if it is not the same as the policyholder s address. 6 Patient Relationship to Insured Check the appropriate box. Do not use the box for Other. 7 Insured s Address Enter the complete address of the policyholder. 8 Through 1/5/2014: Patient Status Starting 1/6/2014: Reserved for NUCC use Through 1/5/2014: Check the appropriate box. Starting 1/6/2014: Leave this field blank. 9 Other Insurance Information Required if 11d is marked yes. If you determine the patient has other coverage, please enter the name of the other insured. 9a 9b Other Insured s Policy or Group Number Through 1/5/2014: Other Insured s Date of Birth Starting 1/6/2014: Reserved for NUCC use Enter the other insured s policy or group number in this field. Through 1/5/2014: Enter the other insured s date of birth (MM/DD/CCYY) and sex. Starting 1/6/2014: Leave this field blank. 9c Through 1/5/2014: Employer s Name or School Name Starting 1/6/2014: Reserved Through 1/5/2014: Enter the employer s name. Starting 1/6/2014: Leave this field blank. for NUCC use 9d Insurance Plan Enter the insurance plan name or program. Block 9d may be used to indicate that a Medicare eligible patient elected not to purchase Medicare Part A or Part B coverage. Enter No Medicare Part A and/or Part B Coverage, depending on the patient s situation. 10 Is Patient s Condition Related To Check the appropriate box if the patient s condition is related to employment or an auto accident or check other. 11d Another Health Benefit Plan Request this information from the member. If the answer is yes, go back and complete blocks 9 9d. 14 Date of Current Illness/ Injury/Pregnancy Enter the date (MM/DD/YY) that applies to accident and medical emergency situations. If you submit services that relate to more than one accident or medical emergency, please submit separate claims for each accident or medical emergency.

36 CMS-1500 Required Field Information Field No. Field Name Explanation 17 Name of Referring Physician or Other Source 17b ID Number of Referring Physician 21 Through 1/5/2014: Diagnosis or Nature of Illness/Injury Starting 1/6/2014: Diagnosis or Nature of Illness/Injury. Relate A L to service line below (24E). Indicate whether ICD-9 or ICD-10 codes are entered. 23 Prior Authorization Number (Note: ambulance pick-up zip code also entered in this field) WHPI claims only Enter the name of the referring physician. For lab and X-ray claims, enter name of the physician that ordered the diagnostic services. All Independent Clinical Lab claims: Enter the name of the physician that completed the specimen draw. All Home Infusion Therapy claims: Enter the name of the prescribing physician. WHPI claims only Enter the referring physician s National Provider Identifier (NPI). All Independent Clinical Lab claims: Enter the NPI of the physician that completed the specimen draw. All Home Infusion Therapy claims: Enter the NPI of the physician that wrote the prescription for the infusion. For dates of service through September 30, 2015, enter an ICD-9- CM code. List the primary diagnosis first. If there is more than one diagnosis, indicate in field 24E which diagnosis(es) applies to the procedure being billed on each line item of the claim form. The 08/05 form accommodates 4 diagnosis codes; the 02/12 form allows for 12 codes. Narrative descriptions are not accepted. Starting with date of service October 1, 2015, use ICD-10 codes. Enter the prior authorization number. A complete list of services subject to prior authorization can be found at Ambulance Service Providers: Enter the pick-up zip code here.

37 CMS-1500 Required Field Information Field No. Field Name Explanation Note on how to supply supplemental information in fields 24A J: For instructions, refer to the1500 Health Insurance Claim Form Reference Instruction Manual ( Examples of supplemental information include: anesthesia start and end times providing a narrative description for an unspecified code supplying the National Drug Code (NDC) for a drug 24A Date of Service From/To If you submit office or hospital outpatient services, submit each service and/or each date of service on a separate line with the same From and To dates. The only exceptions in which we will allow date spanning on a line is if you are: a practitioner billing inpatient services within a month, a home medical equipment (HME) supplier billing the monthly rental of equipment, or a home infusion therapy (HIT) provider billing services provided within a month. For inpatient practitioner visits, you may date span your charges as long as the following are true: the service provided is the same procedure code the dates of service are consecutive services are submitted within the same month Only submit dates for services provided. Wellmark will not process claims for future dates of service. To file HME monthly rentals: submit an appropriate HCPCS (Healthcare Common Procedure Coding System) code with an RR modifier on a separate line either date span for the monthly rental or enter the date the item was rented in both the From and To fields bill one unit of service on the line FEP allows benefits for multiple office visits provided on the same day by the same provider for the same patient, subject to local rules and FEP contract limitations. To indicate that a second visit was performed, add a 25* modifier to the second and subsequent E/M codes. Submit all services provided on the same date of service on one claim. *Current Procedural Terminology 2015 American Medical Association. All Rights Reserved.

38 CMS-1500 Required Field Information Field No. Field Name Explanation 24B Place of Service Enter the place of service code by using the two-digit codes below. Electronic Submitters: Electronic submitters must enter the standard two-digit place of service codes. Paper Submitters: If the place of service code on the claim does not match the procedure code or if you leave this field blank, Wellmark will return the claim. 24D Procedure Codes/Modifiers School Homeless Shelter Indian Health Service-Free-Standing Facility Indian Health Service-Provider-Based Facility Tribal 638 Free-Standing Facility Tribal 638 Provider-Based Facility Prison Correctional Facility Office Home Assisted Living Facility Group Home Mobile Unit Walk-In Retail Health Clinic Urgent Care Inpatient Hospital Outpatient Hospital Emergency Room Hospital Ambulatory Surgical Center Birthing Center Military Treatment Facility Skilled Nursing Facility Nursing Facility Custodial Care Facility Hospice Ambulance Land Ambulance Air or Water Independent Clinic Federally Qualified Health Center Inpatient Psychiatric Facility Psychiatric Facility-Partial Hospitalization Community Mental Health Center Intermediate Care Facility/Mentally Retarded Residential Substance Abuse Treatment Facility Psychiatric Residential Treatment Center Non-Residential Substance Abuse Treatment Facility Mass Immunization Center Comprehensive Inpatient Rehabilitation Facility Comprehensive Outpatient Rehabilitation Facility End Stage Renal Disease Treatment Facility State or Local Public Health Clinic Rural Health Clinic Independent Laboratory Other Place of Service Submit valid CPT* or HCPCS codes. Enter a current two-digit CPT or HCPCS modifier when applicable. 24E Diagnosis Pointer (Conditionally required) When there is more than one diagnosis on a claim, enter the primary diagnosis reference number (on the 02/12 revised form, reference letter) from field 21 that relates to the reason each service was performed. If more than one diagnosis is appropriate for a service, the first number (letter) listed in 24E must be the primary diagnosis for that service. 24F Total Charge Submit a charge for each service billed on a line. *Current Procedural Terminology 2015 American Medical Association. All Rights Reserved.

39 CMS-1500 Required Field Information Field No. Field Name Explanation 24G Days or Units Enter the appropriate number of services (in whole numbers) based on the time period or amount designated by the procedure code. You must enter at least one unit. To bill anesthesia, submit the actual time (in minutes) spent administering anesthesia services. 24J Performing Physician Number (NPI) Note for Independent Ambulance Providers: Wellmark joins the Centers for Medicare and Medicaid Services (CMS) in requiring that claims for ambulance services report mileage to the nearest tenth of a mile when the trip is less than 100 miles. Wellmark can process claims using whole numbers only, and will round up to the nearest whole number ambulance claims reported with a fraction of a mile. For details, see the "Outpatient Services" Provider Guide on Wellmark.com (Provider > Communications and Resources > Provider Guides). (Conditionally required) Complete field 24J if the practitioner s individual rendering/performing NPI number is different from the billing/organization NPI entered in field 33a. Practitioners most likely affected will be those who take part in a group practice that have an organization NPI, or individual practitioners that have an organization NPI. This box is to be left blank if you are not part of a group. Note for Iowa CMHCs: Community Mental Health Centers (CMHC) contracted as entities in Iowa are not required to submit the individual number of employed personnel who provide services. 25 Federal Tax ID Number Enter your practitioner/supplier federal taxpayer identification number (TIN). The number you reported to the Internal Revenue Service and to Wellmark is the number that needs to appear in this field. Note: If the federal tax number is not given or if the number given is less than nine digits, Wellmark will return the claim to you. 26 Patient s Account No. This is a required field for electronic submitters. 27 Accept Assignment This is required for Medicare-related claim submissions only. 28 Total Charges Enter the total of all charges from 24F. The line items submitted must equal the Total Charge in field 28 or the claim will be returned. If you submit a paper claim that has more than six line items, do not total the charge on the first claim form. Indicate continued in this field and attach additional claim forms until all services have been submitted. On the final claim form, submit the total charge.

40 CMS-1500 Required Field Information Field No. Field Name Explanation 31 Signature of Physician The physician s signature, a computer-printed name, a stamp facsimile, Signature on File, or the signature of an authorized person is acceptable. The signature identifies that the services reported on the claim were provided by the practitioner or under the personal supervision of the practitioner. 32 Service Facility Location Information (Conditionally required) When services are provided in a state other than where the services are billed from, provide the name and address (city and state) of the facility where the services were provided. 32a. NPI Enter the facility s NPI number. Providers of service (physicians) must identify the supplier s name, address, zip code, and NPI number when billing for purchased diagnostic tests. When more than one supplier is used, a separate claim should be used to bill for each supplier. 33 Physician/Supplier s Billing Number and Address Enter the provider s or supplier s billing name, address, zip code, and phone number. 33a. NPI If you have a group/organization NPI number, enter it in this field. If you do not have a group/organization NPI, enter your individual practitioner s/supplier s NPI number in this area.

41 Providers required to file on the 837I or the UB-04 Wellmark requires the following facilities to submit the 837I or the Uniform Bill (known as the UB-04 or HCFA-1450). 837I/UB-04 Submitters by Provider Type Ambulatory Surgery Center (ASC) Notes Chemical Dependency Treatment Facility Freestanding and Hospital-based Dialysis Center/ End-Stage Renal Disease Freestanding and Hospital-based Freestanding Substance Abuse Facility Home Health Agency Freestanding and Hospital-based Hospice Freestanding and Hospital-based Hospital Psychiatric Medical Institute for Children Skilled Nursing Facility Freestanding and Hospital-based (CDTF) (ESRD) (FSAF) (HHA) (PMIC) (SNF) Licensed South Dakota facility approved to provide treatment for chemical dependency conditions. FSAF Iowa license Iowa only The next page shows an example of the UB-04, followed by a chart that identifies the required fields you must complete for Wellmark to process claims accurately. The numbers to the left of the chart correspond to the form locator (FL) fields on the claim form. If one or more of the "required" fields are left blank or are incomplete, the claim will be rejected. The Provider Claim Remittance (PCR) will indicate one of the following reasons if a claim is rejected for missing or invalid information: member information provider information diagnosis or procedure code alpha prefix patient relationship to insured information on the claim (general) UB-04 required fields for claim submission Submit the updated claim as a new claim. Do not attach it to a Provider Inquiry form. See the Claims Denied for Missing Information section for more information.

42 The UB-04 Required Field Information chart provides basic filing instructions you need to submit services for payment. For detailed coding instructions, refer to the UB-04 Data Specifications Manual at For specific electronic filing instructions, refer to the Wellmark Companion Guide found at Wellmark.com (Provider > Claims & Payments > Electronic Transaction/HIPAA Guides). To ensure accurate procedure and diagnosis coding, use the code sets identified in the Coding Claims section of this guide. NPI Note: To avoid claim rejections, notify Wellmark of your NPI number prior to using it on a claim. Facility-specific provider guide Facility Specific Billing Information If you need more specific billing information based on the type(s) of services you provide (e.g., hospital, skilled nursing, home health), refer to the Guide to Billing Facility Services. This guide addresses how to bill inpatient, outpatient, and home services and can be found at Wellmark.com (Communication and Resources > Provider Guides).

43 Name and address of the facility providing the service are required. Required Required Required Required Required Required Required except TOB14X Required Conditionally required Conditionally required Required if inpatient Conditionally required Required Required Required if part of the provider s contract. Required on outpatient claims that have date spans. Required A charge is required for each service. When there is no charge, enter $0.00. Conditionally required Required Required Conditionally required The policyholder s name and the patient s relationship to the policyholder are required. Required A valid ICD-9-CM principal diagnosis and other diagnoses, if applicable, are required in these fields. A POA indicator is required for each diagnosis for inpatient claims. Conditionally required Conditionally required inpatient: An ICD-9-CM Volume 3 procedure code and date are required. Conditionally required

44 UB-04 Required Field Information Field No. Field Name Explanation 1 None Enter the facility s name and address. 4 Type of Bill Enter the appropriate four-digit code (e.g., 011X) as specified in the UB-04 Data Specifications Manual. 1 st digit Leading zero (0) 2 nd digit Type of facility 3 rd digit Type of care 4th digit Indicates the sequence of the bill for a specific episode of care The Type of Bill you submit must coincide with your provider number (FL51) and each revenue code you submit in FL 42. For instructions on how to complete this form locator to submit interim or series bills, see the Interim Billing section in this guide. 5 Federal Tax No. Enter your facility s nine-digit number for the type of bill you are submitting (e.g., NN-NNNNNNN). 6 Statement Covers Period (From Through) Enter dates in the MM/DD/YY format. This field shows the beginning and ending dates of service for the entire period submitted on the claim. If there is a date span given in FL 6, you must enter a date of service in FL 45 for each service billed with the exception of the following services: -inpatient hospital -swing-bed -skilled nursing facility For more detailed information on how to submit dates of service that span months or years, see the How to Bill Date Spans for Inpatient Services/Accommodation Charges section in this guide. For details on billing situations which involve outpatient, observation bed, and inpatient services, see the "Outpatient Services" Provider Guide on Wellmark.com (Provider > Communications and Resources > Provider Guides). 8a Patient Name Enter the patient s last name, first name and middle initial. 8b Patient ID Number Enter the patient s ID number (if different from the policyholder s ID number). 9a-d Patient Address Enter the patient s full address, even if the patient s address is the same as the policyholder s. 10 & 11 Patient Birth Date and Sex Enter the correct date of birth (MM/DD/YYYY) and sex of the patient. 12 Admission/Start of Care Date Enter the date the patient was admitted for inpatient care. 14 Priority (Type) of Admission or Visit Required on inpatient only. This code indicates priority of admission (e.g., emergency = 1, urgent = 2, elective = 3, etc.). Refer to the UB-04 Data Specifications Manual for a listing of codes.

45 UB-04 Required Field Information Field No. Field Name Explanation 15 Point of Origin for Admission or Visit (formerly Source of Admission) The point of origin (PoO) is where the patient came from before presenting to the health care facility. Based on this definition, the emergency room code has been eliminated. Refer to the UB-04 Data Specifications Manual for a listing of codes. Required on inpatient and outpatient claims except for TOB14X. 17 Patient Discharge Status The patient status code indicates the patient s status as of the Through date of the billing period (FL 6). Required for all institutional claims Condition Codes (Conditionally required) Refer to the UB-04 Data Specifications Manual on how to complete FLs Occurrence Codes and Dates Occurrence Span Code and Dates (Conditionally required) Occurrence codes are required when there is a condition code that applies to the claim. Refer to the UB-04 Data Specifications Manual for a list of occurrence codes. Inpatient: Enter event codes and a beginning and ending date that define a specific event relating to the billing period. Refer to the UB-04 Data Specifications Manual for a list of occurrence codes Value Codes and Amounts (Conditionally required) Enter the two-digit value code(s) and dollar or unit amount(s) necessary to process the claim. Refer to the UB-04 Data Specifications Manual for a list of value codes. 42 Revenue Code This field allows for a four-digit revenue code that represents a specific accommodation, ancillary service, or billing calculation. Revenue codes must be valid for the Type of Bill (FL 4) indicated on the claim form. 43 Revenue Description Complete this field with the standard description assigned each revenue code. A list of revenue codes and their descriptions can be found in the UB-04 Data Specifications Manual. 44 HCPCS/Rate/HIPPS Codes Enter HCPCS codes if required by your provider contract. 45 Service Date Required on all outpatient claims when a date span is given in the Statement Covers Period (FL 6). You must provide a specific date for each service billed on a line.

46 UB-04 Required Field Information Field No. Field Name Explanation 46 Service Units This field identifies the number of services the patient received (e.g., the number of days in a particular accommodation) or the time required to provide a specific service (e.g., anesthesia, group psychotherapy). To calculate units, round up to the nearest whole number. On inpatient claims, we require at least one unit of service for each revenue code billed. The units of service field must match the total number of days indicated in FL 6. Each 24-hour period is calculated as one day. Note for Hospital-Based Ambulance Providers: Beginning with date of service on or after October 1, 2012, Wellmark joins the Centers for Medicare and Medicaid Services (CMS) in requiring that claims for ambulance services report mileage to the nearest tenth of a mile when the trip is less than 100 miles. Wellmark can process claims using whole numbers only, and will round up to the nearest whole number ambulance claims reported with a fraction of a mile. For details, see the "General Medical" Provider Guide on Wellmark.com (Provider > Communications and Resources > Provider Guides). 47 Total Charges Submit a charge for each revenue code billed. Even if there is no charge, you must either enter 0.00 or N/C on the line item or the claim will be returned. 50 Payer Identification Enter Blue (space) Cross (space) 140 for Iowa and 141 for South Dakota. Enter the Blue Cross Plan Code for BlueCard members in this field. If other than BlueCard, enter the name(s) of the patient s other insurance company or carrier. 54 Prior Payments (Conditionally required) Enter any amount the facility has received toward payment of this bill prior to the billing date by the indicated payer in FL National Provider ID (NPI) Enter the facility s NPI number. 58 Insured s Name Enter the last and first name of the policyholder, using a comma or space to separate the two. Do not leave a space after a prefix (e.g., MacBeth). Submit a space between hyphenated names (e.g., Smith Simmons) rather than a hyphen. If the name has a suffix (e.g., Jr., III), enter the last name followed by a space and then the suffix (Miller Jr., Roger).

47 UB-04 Required Field Information Field No. Field Name Explanation 59 Patient s Relationship Enter a code that indicates the relationship of the patient to the policyholder. Refer to the UB-04 Data Specifications Manual for a complete list of appropriate codes you should use to complete this field. 60 Identification Number Enter the alpha prefix and identification (ID) number as it appears on the patient s ID card. 63 Treatment Authorization Codes Enter authorization number[s]. Line A: Procedure authorization number Line B: Facility authorization number A complete list of services subject to authorization is found at 67 Principal Diagnosis Enter the principal ICD-9-CM diagnosis for the condition established, after study, as responsible for the patient s admission. 67A 67Q Other Diagnosis Codes Present on Admission (POA) Indicator Enter the full ICD-9-CM codes for additional conditions if they co- exist at the time of admission, or develop subsequently and have an effect on treatment or length of stay. The POA is the eighth digit of FL67 and each of the secondary diagnosis fields FL 67A-Q. 74 Principal Procedure Code and Date 76 Attending Physician Name and Identifiers 77 Operating Physician Name and Identifiers Code Y N U W 1 Blank Definition Diagnosis present at time of admission Diagnosis NOT present at time of admission Documentation insufficient to determine Clinically Undetermined Unreported/Not used (equivalent to blank on the paper (UB-04) Unreported/Not used (Conditionally required) On inpatient claims, submit a valid principal ICD-9-CM Volume 3 procedure code, including the fourth and fifth digits, when revenue codes , , and are billed. (Required for inpatient; submit for outpatient, if applicable) Enter the name and NPI number of the licensed physician who normally would be expected to certify and recertify the medical necessity of the services provided, and/or who has primary responsibility for the patient s medical care and treatment during an inpatient stay. (Conditionally required) Required when a surgical procedure code is listed on the claim. Enter the: name NPI number

48 How to Bill Date Spans for Inpatient Services/Accommodation Charges The following information explains how to file inpatient charges billed: 1) within a month; 2) over two or more months; and 3) that cross years. These instructions apply to inpatient claims for all Wellmark members, including FEP members and patients who have out-of-state Blue Cross and Blue Shield coverage. One unit of service equals a 24-hour period 6 STATEMENT COVERS PERIOD FROM THROUGH 08/02/YY 08/26/YY A day is counted as a 24-hour period. Our claims processing system views each "Through" date on a claim as the discharge date. Since discharge dates are not a full 24-hour stay, we do not consider that day a unit of service. To calculate the correct number of units, do not count the "Through" date or the discharge date as a unit of service on any inpatient claim you file. The following are different scenarios to help you understand the correct way to bill these services. Inpatient Services Within the Same Month A member is admitted August 2, YYYY and discharged August 26, YYYY. In this example, the "From" and "Through" dates you should submit in FL 6 are 08/02/YY 08/26/YY. If you count the total number of days from August 2 26, there are 25. However, since Wellmark does not consider the "Through" date or discharge date as a full day, only submit 24 units in FL RV. CD 43 DESCRIPTION 44 HCPCS/RATES 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED CHARGES $10, Inpatient Services that Span Months The same holds true when you bill inpatient charges that span months. In this example, a member was admitted July 10, YYYY, and discharged September 16,YYYY. To submit this inpatient stay, you can either file one claim or submit an interim bill (which is described in the Interim Billing section of this guide). On the initial claim, submit dates of service 07/10/YY 08/01/YY. You must bill August 1 as the "Through" date in order to receive payment for July 31. To calculate the units of service, only count the days from July 10 31, which are 22. Since our system sees August 1 as the discharge date, we will not allow payment for that date of service on the initial claim. On the second claim, submit dates of service 08/01/YY 09/01/YY, with 31 units of service. Submit August 1 as the "From" date on the second claim so that it is counted as a 24-hour day and you receive payment for it. On the final claim, the "From" and "Through" dates in FL6 should be 09/01/YY 09/16/YY. To calculate the units of service, count the days from September 1 15, which are 15. Since September 16 is the discharge date, you would not count it as a 24-hour stay or include it in the units of service. Remember, interim bills must be submitted in sequential order for Wellmark to process and pay them correctly.

49 First Claim There will be times when we ask for a breakdown of charges by month when you are billing inpatient services that span months. This will happen most often if the member's coverage changes from one insurance company to another during an inpatient stay. If you are aware that a member's coverage has changed, we encourage you to submit services provided within each month on separate claims. This will expedite claims processing and payment. Inpatient Dates of Service that Span Years To bill inpatient services that span years, submit an interim bill: one for the services received up through the end of the year; another for the services received in the new year. Below is an example that explains how to complete FLs 6 and 46 for services that span years. A member is admitted December 27, 2014 and discharged on January 6, To bill this stay correctly, submit December 27 January 1 on the first claim. As when billing services that span months, you need to bill January 1 on the initial claim to receive payment for December 31. Since our claims processing system views January 1 as the discharge date, bill only 5 units of service in FL 46. First Claim 6 STATEMENT COVERS PERIOD FROM THROUGH 12/27/14 01/01/15 12/27/13 01/01/14 42 RV. CD. 43 DESCRIPTION 44 HCPCS/RATES 45 SERV. DATE 46 SERV UNITS 47 TOTAL CHARGES 48 NON-COVERED CHARGES $2, STATEMENT COVERS PERIOD FROM THROUGH 01/01/15 01/06/15 To receive payment for the services provided on January 1, submit it as the "From" date on the second claim with the "Through" date being January 6, Again, since January 6 is the discharge date and is not considered a full 24-hour stay, you would only bill 5 units of service on the second claim. Second Claim 42 RV. CD. 43 DESCRIPTION 44 HCPCS/RATES 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED CHARGES $2, FEP allows claims that span years FEP exception: Effective July 1, 2013, the Federal Employee Program (FEP) allows inpatient facility claims to span two calendar years. Interim bills will no longer be required for FEP claims that span years.

50 Interim Billing Hospitals submit interim claims to bill extended inpatient stays that span months. When submitting interim claims: Type of Bill must be in sequential order Necessary form locators for interim claims submit the claims in sequential order (e.g., Type of Bill 0112, 0113, 0114). Wellmark will deny the claim if it is submitted: -out of sequence -before the previous claim is paid Resubmit the denied claim once the prior claim is processed. complete the following form locators: - (FL 4) Type of Bill in FL 4 - (FL 6) the "From" and "Through" dates in the Statement Covers Period - (FL 17) the Patient Status Code The Type of Bill and the Patient Status must be related, or the claim will be denied. Claim Order Type of Bill (FL 4) Statement Covers Period (FL 6) Patient Status Code (FL17) First 0112 From and Through Dates 30 Successive 0113 From and Through Dates 30 Last 0114 From and Through Dates 01-04, 06, 08, 20, or 62 Examples of key UB-04 form locators First Claim ADMISSION 12 DATE 13 HR 14 01/07/YY 6 STATEMENT COVERS PERIOD FROM THROUGH 01/07/YY 02/01/YY 66 DX A B C I J K L 74 PRINCIPAL PROCEDURE CODE DATE /07/YY c. OTHER PROCEDURE CODE DATE 4 TYPE OF BILL STAT 30 a. OTHER PROCEDURE CODE DATE d. OTHER PROCEDURE CODE DATE b. OTHER PROCEDURE CODE DATE e. e. OTHER PROCEDURE CODE DATE CODE DATE 66 DX I J Successive Claim ADMISSION 12 DATE 13 HR 01/07/YY 6 STATEMENT COVERS PERIOD FROM THROUGH 4 TYPE OF BILL /01/YY 03/01/YY 17 STAT 74 PRINCIPAL PROCEDURE CODE DATE 30 a. OTHER PROCEDURE CODE DATE /07/YY /02/YY c. OTHER PROCEDURE CODE DATE d. OTHER PROCEDURE CODE DATE b. OTHER PROCEDURE CODE DATE e. OTHER PROCEDURE CODE DATE

51 Final Claim ADMISSION 12 DATE 13 HR 14 TY 01/07/YY 66 DX I J 6 STATEMENT COVERS PERIOD FROM THROUGH 4 TYPE OF BILL /01/YY 03/05/YY 17 STAT 74 PRINCIPAL PROCEDURE CODE DATE 62 a. OTHER PROCEDURE CODE DATE /07/YY /02/YY c. OTHER PROCEDURE CODE DATE d. OTHER PROCEDURE CODE DATE b. OTHER PROCEDURE CODE DATE e. OTHER PROCEDURE CODE DATE The initial admit date must appear on all subsequent claims List all diagnoses on all claims List all surgeries on all claims Interim claims payment How to submit a member s transfer during an interim stay Additional Interim Billing Tips Submit the same admit date for all claims dealing with the same acute event. Unless the member is discharged from the acute level of care, use the initial admit date as the admit date on all subsequent claims. Wellmark reimburses covered services based on the member's benefits in effect on the initial admit date. Claims will be denied if you submit an admit date other than the admit date entered on the initial claim (TOB 0112). List all the diagnoses on the first and subsequent claims. If the member's condition declines after TOB 0112, claims that follow should list the new and previous diagnoses. List all ICD-9-CM Volume 3 surgical procedures on the first and all subsequent claims, even if the surgery was filed on a prior claim. Wellmark evaluates the diagnoses and surgical procedure codes from each claim associated with an event. Payment is made on the initial claim (TOB 0112) based on the diagnoses and surgical procedure codes given. After that, no additional payment is made until discharge (TOB 0114). Wellmark calculates payment on the highest weighted DRG and makes any additional payments or recoupments based on the initial payment from TOB Member Transfer During an Interim Stay When a member is transferred from acute inpatient to a skilled level of care at the same facility, take the following steps to submit the UB-04: Submit the correct Type of Bill. If a member is being transferred to a skilled level of care, submit a discharge TOB rather than an interim TOB. Discharge the member from the acute level of care. Admit the member to the skilled level of care using your skilled provider number. If the member returns to acute care, use the date of return as the new admit date. How to Submit Outpatient Services Outpatient services are either performed in a series or as a one-time encounter. The following information explains how to complete the UB-04 for each situation.

52 Outpatient services performed in a series Outpatient one-time encounters within the same month Separate date of service required for certain TOBs Revenue codes that require CPT/HCPCS codes Revenue code 278 Pseudo Singleton list Outpatient services performed in a series (e.g., chemotherapy, infusion, dialysis, physical or occupational therapy), for the same member, within the same month, should be submitted on one claim form. Do not date span months on one claim, or it will be returned (see Series Claims Billing information below). When an outpatient service is a one-time encounter (surgical or diagnostic), submit that occurrence on a separate claim form. Do not bill it with other outpatient services that have occurred within the same month. Note: The only time we will allow multiple outpatient surgeries on the same claim is when the procedures occur on the same day. Other Outpatient Billing Information Submit a separate date of service in FL 45 for each line billed when the following Types of Bill are submitted: 013X, 014X, 023X, 032X, 034X, 071X, 072X, 074X, 075X, 081X, 082X, 083X, 084X, 085X, and 086X. Note: These bill types do not apply to hospital inpatient, swing-bed, or skilled nursing claims. Certain revenue codes require a CPT*/HCPCS code in FL 44. A complete list of revenue codes can be found at Wellmark.com (Provider > Claims and Payment > Outpatient Facility Claims [UB-04]). Implants and Revenue Code 278 To reduce delays and receive appropriate outpatient hospital payment when billing revenue code 278, please submit CPT/HCPCS codes for implants included in the Wellmark Pseudo Singleton listing. Such detailed coding is not required for implants not on this list. The Pseudo Singleton list may be found on the secure Treo website at To gain access to the Treo site, contact your Wellmark Network Engagement Business Partner in Iowa or South Dakota. Iowa and South Dakota Hospitals and Facilities may all log onto the secure Treo website at the address above. Types of Bill for series claims Series Claims Billing When you bill series claims for outpatient therapy or chemotherapy treatment, submit each month's services on a separate claim along with the appropriate Type of Bill in FL 4 and Service Date in FL 45. Submit the following codes to indicate the appropriate Type of Bill: 0132 for the first claim covering services in one month; 0133 for any continuing or interim claim(s); and 0134 for the last claim. 3 PATIENT CONTROL NUMBER 4 TYPE OF BILL 0132 Enter the first and last dates of service billed within the month in the Statement Covers Period (FL 6). 6 STATEMENT COVERS PERIOD FROM THROUGH 02/03/YYYY 02/26/YYYY *Current Procedural Terminology 2015 American Medical Association. All Rights Reserved.

53 List each date of service separately in FL 45. Bill dates of service within a month on one claim form. Always enter "1" in the Service Units (FL 46). The CPT* code you use to identify the service will indicate the length of time if time is required. 42 RV. CD. 43 DESCRIPTION 44 HCPCS/ RATES 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 914 PSYCH/INDIV RX /03/YYYY 1 AMOUNT 915 PSYCH/GROUP /10/YYYY 1 AMOUNT 914 RX PSYCH/INDIV RX /17/YYYY 1 AMOUNT 914 PSYCH/INDIV RX /26/YYYY 1 AMOUNT 48 NON- COVERED CHARGES 49 Submitting Corrections for Facility Claims Wellmark prefers all charges for the date of service be submitted on a single claim. If corrections to an original claim for inpatient and outpatient services are needed, use the appropriate Type of Bill (TOB) in FL 4 on the UB-04. Be sure to use the correct TOB, as defined below, to indicate the changes being made to the original claim. Submit corrected claims only after the original claim has finalized and generated a Provider Claim Remittance (PCR). All claims can be corrected and submitted electronically, regardless of how they were filed initially, saving you time and expediting any adjustments. A Provider Inquiry form does not need to be completed for corrected claims with TOB greater than 5. For a list of corrections that must be submitted in writing and when an inquiry must be submitted, see the Claim Corrections Which Must Be Submitted in Writing section of this guide. Filing Corrected Claims Simply file the corrected claim, using one of the following as the final digit of the claim's type of bill (TOB): FINAL DIGIT TOB WHEN TO USE 5 Late charges only 7 Replacement of a prior claim 8 Void/cancel of a prior claim Late Charges only Wellmark prefers all charges to be received on the original submission; however, in the event that services need to be added, a corrected claim is required. Wellmark refers to late charges as services submitted on a corrected claim, for the same date of service, at a later date than the original claim submission. When late charges need to be added to the claim after the original claim finalizes, a corrected claim with TOB XX5 should be submitted for the additional charges only. Do not include any charges billed on the original claim or any other changes (e.g., diagnosis change, revenue code change, etc.). *Current Procedural Terminology 2015 American Medical Association. All Rights Reserved.

54 Replacement of a Prior Claim Wellmark refers to a replacement claim as one or more changes to the original claim submission. When corrections other than late charges only need to be made to a previously billed claim, a corrected claim with TOB XX7 should be submitted with the changes and must include all charges for the date span billed. The original claim could be replaced due to late credits (removing a charge from a claim), diagnosis change, revenue code change, etc., and could include late charges. Void/Cancel of a Prior Claim When a finalized claim needs to be voided or cancelled, submit the original charges on a corrected claim with TOB XX8. For example, the claim was originally billed in error or place of service has changed on the facility claim. Avoid denials on corrected claims Note: The original claim must be finalized prior to submission of the corrected claim. If the corrected claim is received before original claim finalizes, the corrected claim will be rejected. Do not submit multiple corrected claims until the prior claim record is finalized. Any subsequent corrected claims will be rejected if received prior to the previous claim record finalizing. Any changes made to the first two digits of the TOB, must be made using the void/cancel of a prior claim process and resubmit as a new claim. If a facility claim is changing from outpatient to inpatient or vice versa, TOB must be submitted as the final digit 8. Submit as a new claim. Note: The place of service cannot be changed from inpatient to outpatient on an adjustment. The TOB must be appropriate for the changes made on the claim. For example, the final digit "5" means late charges only; no other changes can be listed on the claim. If a TOB greater than 5 is received, but no changes have been made, the claim will be rejected. If a corrected claim is submitted, but there is no original claim on file, the claim will be rejected. If a corrected claim is received with missing or invalid information, the claim will be rejected. If Wellmark is the secondary payer on late charges or replacement of a prior claim, please submit the corrected primary carrier payment information with the corrected claim. For more information on coordination of benefits, refer to the Coordination of Benefits section in this guide.

55 The following information identifies the fields on the CMS-1500 and UB-04 you need to complete for accident/injury claims, and explains what information is needed to file vehicle and work-related injuries. Diagnoses that require an accident date CMS-1500, UB-04, and Electronic Submission Field Requirements for Accident/Injury Claims When a claim is submitted with a diagnosis from the following range of ICD-9- CM codes, Wellmark requires the accident/injury date. If the date is not entered, Wellmark considers the claim under the member's health benefits. Accident/Injury ICD-9-CM Codes To submit accident/injury claims, complete the following information on the CMS-1500, UB-04, and electronic claims forms. Complete these fields on the CMS-1500 Complete these fields on the UB-04 CMS-1500 Required Fields for Accident Claims Field Description 21 Diagnosis 14 Accident/Injury date 10 Is condition related to employment, a vehicle accident, or other type of accident? Field UB-04 Required Fields for Accident Claims Description 67 Diagnosis Occurrence Codes Note: The date associated with these occurrence codes cannot be after the "through" date of the Statement Covers Period (FL6). 31 Accident/Injury Date

56 Electronic professional required fields Electronic Professional Required Fields for Accident Claims Loop Segment Description 2300 HI01 = BK Diagnosis 2300 DTP01=439 Accident/Injury date 2300 CLM11-1 Is condition related to employment, a vehicle accident, or other type of accident? Electronic institutional required fields Supplemental accident coverage Diagnosis and E-codes Instructions for filing vehicle accidentrelated services Electronically Electronic Institutional Required Fields for Accident Claims Loop Segment Description 2300 HI01 = BK Diagnosis 2300 HI01-1 = BH Occurrence Code Note: The date associated with these occurrence codes cannot be after the "through" date of the Statement Covers Period HI01-4 Accident/Injury Date Some benefit plans include supplemental accident coverage. Typically, this coverage has a dollar limit (e.g., $1000 per member, per accident) and pays first dollar for accident-related services provided within 90 days from the accident date. When a claim is submitted with an accident diagnosis and accident date, services are first processed under the supplemental accident coverage. After the supplemental accident benefits are exhausted, the remaining charges are processed under the member's health benefits. If a member's condition is related to an accident or injury, it is appropriate to submit the accident or injury as the primary diagnosis and the condition you are treating as the secondary diagnosis. While E-codes help explain why an accident/injury occurred, they cannot be used as a primary diagnosis. E-codes have no influence on whether a claim is processed under a member's medical or supplemental accident benefits. Filing Vehicle Accident-Related Claims When medical services are the result of a vehicle accident, complete the claim fields indicated on page 50 or 51. If you know the amount the other carrier paid, enter that amount in field 29 on the CMS-1500 or FL 54 on the UB-04 and attach a copy of the primary carrier's Explanation of Benefits (EOB). When filing electronically, submit AM in the loop 2320 SBR09 segment, submit the paid amount in loop 2320 AMT02 where AMT01 = D. Submit the Other Payer Subscriber information (name and address) in the 2330A loop. Submit the Other Payer information (name and address) in the 2330B loop. Also include the other payer paid amount in the 2430 SVD02 segment. In the loop 2430 CAS segment, include any claim adjustment group and reason codes that apply. For additional details regarding electronic claims filing, go to Wellmark.com (Provider > Provider Guides > Electronic Transaction/HIPAA guides).

57 File claims with the automobile insurance company and Wellmark at the same time in order to meet Wellmark's timely filing guidelines. It is not necessary to wait for the automobile carrier to pay before filing with Wellmark. Instructions for filing work-related services Letters are sent to members asking for information Filing Workers' Compensation Claims When medical services appear to be work-related, complete the claim fields indicated in the How to File Accident/Injury-Related Claims section in this guide. File claims with the member's Workers' Compensation carrier and Wellmark at the same time to meet Wellmark's timely filing guidelines. You do not have to wait for the other insurance carrier or Workers' Compensation to pay in order to submit charges to Wellmark for consideration. Member Questionnaires If a diagnosis indicates that the condition may be work-related, Wellmark investigates before settling the claim. A letter questioning Workers Compensation is sent to the member. If an answer is not received within 25 days, we deny the claim. When we receive a response from the member, one of two actions occurs: 1) If subrogation is involved, the claim will normally be reprocessed to allow benefits; and 2) If Workers Compensation is involved, the claim will remain denied and should be submitted to the Workers Compensation carrier. When member does not respond Provider option when member fails to respond BlueCard Host Workers Comp claims A message will appear on your Provider Claim Remittance (PCR) when the member has not responded to the questionnaire: 1) Possible work-related condition, no response from member. Provider Response Option When claim processing is delayed because Wellmark is waiting for a response from the member, providers now have an option to move the claim along. Two buttons on the claims summary screen of the Check a Claim tool found on our secure Provider page on Wellmark.com allow the provider to indicate whether the claim is due to a work-related injury or an accident. The provider response to BlueCard Host claims submitted for Workers Compensation for another Plan s member will be forwarded to the member s plan. The member s Home Plan will determine if the claim can be processed with the response provided. How to Correct Payment on Services that were paid by Workers Compensation or Auto Insurance If Wellmark has paid for services that are later paid as primary by the Workers' Compensation carrier or auto insurance, notify us by: Submitting a Provider Inquiry Form and indicating the claims that need adjusting. Circling the claims that need correcting on attached PCRs. Attach a copy of the other carrier's Explanation of Benefits (EOB) that shows what they paid. Wellmark must have documentation to reprocess If Wellmark needs to recoup payment, we will either recoup automatically or send your office a request for refund.

58 For most contracts, if a member is injured due to the negligence of a third party and recovers damages from this third party, subrogation entitles Wellmark to seek reimbursement from the member for any amounts settled in that person's behalf as a result of the accident. How to Refund a Payment If we determine an overpayment has been made on a claim and payment is not automatically deducted, follow these instructions: 1) Send a copy of the PCR that involves the overpayment. Circle the patient's name and the amount we paid on the report. 2) Attach a copy of the other carrier's EOB that shows what they paid 3) If the claim payment is not automatically deducted, you may write a check payable to Wellmark along with documentation to: Claims Financial Mail Station 5E 289 Wellmark Blue Cross and Blue Shield PO Box 9232 Des Moines IA Wellmark s COB policy Coordination of benefits (COB) is designed so that maximum allowable benefits are not exceeded between all coverages when: a person is covered by more than one group or individual health insurance plan the medical portion of a person's automobile insurance is involved the medical portion of a person's long-term care policy is involved individual plans contain a COB clause Wellmark does not coordinate benefits with: Medicaid CHAMPUS school accident insurance, except when the school/student accident insurance has a COB clause Medicare supplemental policies accident-only coverage specified disease or specified accident coverage Wellmark coordinates reimbursement up to our provider allowance (e.g., maximum allowable fee) when we are the secondary payer for practitioner and facility services.

59 Secondary COB claims examples Deductible satisfied The following examples show how Wellmark processes secondary COB claims. Example A Both carriers pay benefits at 80 percent and the deductible has been satisfied. Charge $100 Carrier A Allowance $80 Carrier A Payment $80 x 80% = $64 Wellmark s Allowance $70 Wellmark s Projected Prime Payment $70 80% = $56 Wellmark s Allowance minus Carrier A Paid Amount $70 - $64 = $6 Wellmark's Paid Amount $6 (lesser of $56 or $6) Wellmark contracting providers cannot bill Wellmark members for amounts exceeding Wellmark's allowance (or maximum allowable fee). In this example, Wellmark's allowance was $70. The provider is to be paid a total of $70 with a payment of $64 from Carrier A and a payment of $6 from Wellmark. As a result, the member would have no out-of-pocket liability to the provider. Primary carrier applies deductible Example B In this example, Carrier A's allowance is applied to the member's deductible. The member has a $20 office copayment with Wellmark. Charge $100 Carrier A Allowance $80 Carrier A Payment $0 Wellmark s Allowance $60 Wellmark s Projected Prime Payment $60 - $20 copay = $40 Wellmark s Allowance minus Carrier A Paid Amount $60 - $0 = $60 Wellmark's Paid Amount $40 (lesser of $60 or $40) Since Wellmark's allowance is $60, a Wellmark contracting provider can bill the Wellmark member the $20 copayment. Both carriers apply deductible Example C In the following example, both carriers apply deductible (ded.) and coinsurance. Charge $200 Wellmark s Allowance $150 Carrier A Allowance $200 Wellmark s Projected Prime Payment ($150 - $50 ded.) 80% = $80 Carrier A Payment ($200 - $100 ded.) x 80% = $80 Wellmark s Allowance minus Carrier A Paid Amount $150 - $80 = $70 Wellmark's Paid Amount $70 (lesser of $80 or $70) Wellmark contracting providers cannot bill Wellmark members for amounts exceeding Wellmark's allowance (or maximum allowable fee). In this example, Wellmark's allowance was $150. The provider is to be paid a total of $150 with a payment of $80 from Carrier A and a payment of $70 from Wellmark. As a result, the member would have no out-of-pocket liability to the provider.

60 Note: A change in payment may occur when Wellmark is the secondary carrier and the Wellmark allowance is lower than the primary carrier's allowance. Secondary COB processing does not apply to: claims that pay nothing, such as when the entire amount of the claim is applied to deductible, copay, and/or coinsurance BlueCard host claims (dependent upon Home Plan's COB methodology) Information on how coordination of benefits is handled in these situations is explained on in the Coordination of Benefits section in this guide. In some cases, a self-funded group may request a different payment methodology. Children covered by more than one health plan Instructions for filing COB claims For dependent children covered by two insurance carriers, the "birthday rule" applies. This rule states that the parent whose birthday comes first in the year is primary. We follow this guideline unless there is a divorce situation or court documents dictate otherwise. When you submit a claim for a member who also has coverage with an insurance carrier other than Wellmark, complete fields 9a d on the CMS-1500 or FLs on the UB-04 with the following information: name of the person carrying the other coverage insurance carrier's name and address member's ID number It's important that you bill both carriers the same charges. Do not change charges based on a carrier's reimbursement or allowed amount. If charges do not match those reflected on the member's Explanation of Benefits (EOB), we will return the claim for correction. Wellmark as secondary payer Electronic submission If you know who the primary carrier is, please file the claim with that carrier first. When Wellmark is the secondary carrier, you may submit non-medicare primary payment information to Wellmark electronically or by submitting a paper claim form. To submit claim information electronically, enter the primary payer's information as follows: Claim level loop 2320 Service line level loop Add the other payer's total amount paid to the claim level in loop If the primary payer provides payment information at both the claim and service line levels, enter that information in the designated loops. For claims involving Medicare, Wellmark accepts claims through the national Coordination of Benefits Contractor (COBC). In the event that these claims do not cross over from Medicare, Wellmark accepts this information electronically or on a paper claim form with a copy of the Medicare remittance notice attached. Please allow 30 days (15 days for FEP members) from the Medicare remittance date to submit the claim to Wellmark. For details, go to the Medicare-Related Claims section of this guide.

61 Paper submission Submit COB information on a paper claim by entering the amount the other carrier paid in field 29 on the CMS-1500 or FL 54 on the UB-04. Attach a copy of the primary carrier's Explanation of Benefits (EOB). If you aren't sure with whom to file the claim first, call Provider Service for assistance or file the claim with both carriers at the same time. We coordinate benefits up to Wellmark's allowance (not exceeding the provider's charge). In some cases, a self-insured group may request that we coordinate differently. If our secondary group contract has a nonduplication of benefits provision, we subtract the primary payment from what we would have paid as primary. COB settlement from other carrier We always try to coordinate benefits with the other carrier. Once you receive settlement from the other carrier, please mail or fax the appropriate Wellmark Provider Service a copy of the other carrier's EOB. Identify which claim the EOB belongs to by circling it on the Provider Claim Remittance (PCR). Send a copy of that report or a copy of the original claim to: Provider Service Center Mail Station 5C 139 Wellmark Blue Cross and Blue Shield of Iowa PO Box 9232 Des Moines IA Fax: This area services Alliance Select SM, Classic Blue, Senior Blue, MedicareBlue Supplement SM, Blue Access, hawk-i, Blue Access, Blue Choice, Blue Advantage, SimplyBlue SM, CompleteBlue SM, EnhancedBlue SM, PremierBlue SM, myblue HSA SM, and Blue Rewards SM. Provider Service Center Station 347 Wellmark Blue Cross and Blue Shield of South Dakota 1601 West Madison Street Sioux Falls SD Fax: This area services Classic Blue, Blue Select, Senior Blue, MedicareBlue Supplement SM, SimplyBlue SM, CompleteBlue SM, EnhancedBlue SM, PremierBlue SM, myblue HSA SM. COB and BlueCard The following explains how Wellmark Blue Cross and Blue Shield processes a BlueCard member s CMS-1500 and UB-04 claim(s) when coordinating benefits with another carrier. CMS-1500 Submitters UB-04 Submitters Wellmark Blue Cross and Blue Shield of Iowa and Wellmark Blue Cross and Blue Shield of South Dakota coordinate benefits up to the Host Plan's provider allowance (MAF). Other Blue Plans may choose to coordinate differently (e.g., payment up to charge; payment up to lower allowance). Therefore, it s possible that payment for another Plan's BlueCard members will differ, depending on the payment method chosen by the BlueCard member s Home Plan. Wellmark receives payment information from the BlueCard member s Home Plan, processes the claim(s), and makes payment based on each Plan s COB methodology. When Wellmark is the Host Plan and coordinates benefits for another Plan's BlueCard members on UB-04 claims, the coordination is based on the facility s charge.

62 Coordinating benefits with Medicare COB and Medicare When Wellmark coordinates benefits with Medicare, we coordinate up to Medicare's allowed amount if the provider participates with Medicare. If the provider does not participate with Medicare, we coordinate up to Medicare's limiting charge or total charge, whichever is less. Nonduplication of Benefits Provision Some contracts include a cost-containment COB feature called a nonduplication of benefits provision. This provision, available to large self-funded employer groups, affects our payment in cases where we are the secondary insurer. To determine secondary liability for these contracts, we first view the claim to see what we would have paid as the primary payer. Then, we subtract the primary payer's payment from this amount and pay the balance, if any. The example below illustrates how a $100 service would be processed under standard COB, as well as under COB that contains the nonduplication of benefits provision. Payment Specifics Primary Contract Wellmark Secondary Contract Standard COB Wellmark Secondary Contract COB w/nonduplicati on Maximum Allowable Fee Deductible Coinsurance Approved to Pay Wellmark Allowed Amount Primary Payer's Payment Wellmark's Secondary Settlement (COB) Our Approved to Pay Amount Primary Payer's Payment Wellmark's Secondary Settlement (COB w/ Nonduplication) For the COB contract, we subtract the primary payer's paid amount of $72 from Wellmark's allowed amount of $100, to arrive at our settlement of $28. For the COB with the nonduplication of benefits provision, we subtract the other carrier's payment of $72 from the $80 we would have paid as primary, to arrive at our settlement of $8. When a member has a contract containing this provision, you will see message X252 on a Wellmark remittance report: X252 This member's contract contains a nonduplication of benefits provision. This means that the secondary payment shown on this remittance is the amount we would have paid in the absence of other insurance minus the primary carrier's payment.

63 Double coverage is a term used when a member is eligible for benefits from more than one Wellmark contract within the same Plan. To file a claim for services, submit both ID numbers on the claim form. The Coordination of Benefits department will determine who is primary based on this information. If you know who has primary coverage, enter that information in fields 1a, 4, and 7 on the CMS-1500, followed by the secondary coverage information in field 9a d. Complete FLs on the UB-04 for primary and secondary information. The secondary coverage considers what was paid by the first contract and pays up to the secondary coverage's maximum allowable fee (MAF), unless nonduplication of benefits applies. Refer to the Nonduplication of Benefits Provision section in the guide for more information. If you do not receive payment from the secondary Wellmark contract within two or three weeks of receiving the primary Wellmark payment, please contact the appropriate Provider Service area for assistance. Please do not refile the claim. One benefit of electronic claim submissions is the quick and easy identification of claims that did not transmit due to incomplete or inappropriate information. Such claims are listed on your Z16 report from Wellmark under the heading Claim Error Report. Typically, the Z16 report is sent within one day of your transmission. If you submit a paper claim missing information, we reject the services on your Provider Claim Remittance (PCR) with an F or X code. The F or X code message will tell you to resubmit the claim with corrected or added information. At that point, you should edit the original submission and send to our office as you would if filing a brand-new claim. A claim denied for missing information must be resubmitted as a brand-new claim Remember, do not mark the resubmission as a corrected claim, and do not attach the claim to a Provider Inquiry form. Both indicate that you are submitting a request for an adjustment. Because the original submission did not pass Wellmark s initial processing edits, these claims have not gone through Wellmark's entire claims processing system, and cannot be adjusted. Wellmark will return such resubmissions with a letter asking you to file as a new claim. Note: The resubmitted claim can be submitted electronically, even if the first submission was a paper claim. Resend the completed claim as soon as possible to avoid timely filing issues.

64 Whenever possible, please submit claims electronically. Send new paper claims to one of the appropriate addresses: Addresses for paper claims Iowa Wellmark Blue Cross and Blue Shield of Iowa Station 1E238 PO Box 9291 Des Moines IA Iowa and South Dakota FEP Wellmark Blue Cross and Blue Shield Station 3E463 PO Box 9291 Des Moines IA South Dakota Wellmark Blue Cross and Blue Shield of South Dakota 1601 West Madison Street PO Box 5023 Sioux Falls SD Below are the most common F-code reject messages: F-Code Reject Messages Common F-Code reject messages F001 NPI/TIN numbers submitted do not match NPI/TIN numbers in our system. F031 Procedure code not compatible with place of service. F004 NPI/TIN numbers not valid for the claim s date of service. F035 Services exceed the maximum benefits of insured s contract due to units of service. F009 Legacy provider number was submitted on the claim. Please resubmit using NPI only. F036 Service cannot be performed on patient of this age. F010 The rendering NPI is not found in our system. F039 Diagnosis code incompatible with patient gender. F011 F012 F018 Incorrect patient vs. policyholder relationship. Individual line provider number is required. We do not show you as a participating provider for this member's benefit plan and cannot process this claim. Please resubmit the claim to your local BCBS Plan. F049 F055 F056 We are unable to locate coverage for this person under this ID number. If this person has coverage under a different ID number please resubmit with that number. This multiple provider clinic must submit the performing provider number on each claim line. CPT codes required with revenue codes, please refer to Wellmark Provider Guides. F024 Claim contains invalid diagnosis code. F059 CPT codes required with revenue codes, please refer to Wellmark Provider Guides. F025 Claim contains an invalid procedure code. F060 Services billed with an incorrect place of service. F026 NPI/TIN numbers submitted are not valid for this type of service. F063 Second surgical procedure code is invalid. F030 Procedure code incompatible with patient gender. F066 Third surgical procedure code is invalid.

65 Common F-Code reject messages, cont. F068 F085 F088 This service can only be done 1 time on a single date. Place of service not compatible with provider type. Provider tax number is missing from claim. F-Code Reject Messages F273 First service date is greater than last service date. F274 Admit date is after first date of service. F277 Member address is missing from the claim. F093 Secondary diagnosis code is invalid. F279 Condition date is greater than first service date. F097 Surgical procedure code is invalid. F297 Claim s date of service is after receipt date. F098 Procedure code was cancelled before date of service. F309 Inpatient facility claim needs accommodation line. F121 Tooth number is missing. F320 Hospital days and units of service do not match. F126 Individual provider number not valid with clinic number. F323 Date of first surgical procedure code missing/invalid. F128 Third diagnosis code is invalid. F324 Date of second surgical procedure code missing/invalid. F129 Fourth diagnosis code is invalid. F326 Date of third surgical procedure code missing/invalid. F130 Fifth diagnosis code is invalid. F343 The claim contains an invalid modifier. F135 POA must be a valid value Y, N, W, U, 1 or blank. F148 Room and board units are less than one. F344 Informational message claim denial reason does not apply to this line. F345 Hospital days and units of service do not match. F159 F257 F258 NPI numbers are not found in our system. Total charge does not equal total of individual lines. Service date is prior to patient s date of birth. F260 Condition date required for accident/emergency. F262 Subscriber s name is missing from claim. F386 Units of service must match date span submitted. F420 Inappropriate billing with a 50 modifier. F545 Procedure(s) considered Inpatient Only Service. Please correct and resubmit. F551 Admission hour is required for Outpatient EAPG claim. Resubmit claim with the appropriate admission hour. F577 Admit date and first date of service are incorrect for TOB submitted. Correct and resubmit.

66 Unlisted procedure codes If you cannot find a specific CPT* code that accurately describes the service provided, you may submit an unlisted/not otherwise classified (NOC) procedure code. Whenever you submit an unlisted procedure code, always include a complete description of the code, medical record of the service, and a valid invoice/msrp, if applicable. If documentation is lacking, the claim will deny with one of the following denial codes and claims must be resubmitted with all applicable documentation for processing. Denial Codes Unlisted CPT Range Items Requested X and HCPCS codes Valid Invoice/MSRP required X and HCPCS codes Valid Invoice/MSRP required X Operative Report X Radiology Report X Pathology Report X and HCPCS codes Office Notes X and HCPCS codes Need written description We also reject paper claims with the following X codes, when there is not enough valid information to get the claim past our entry edits. The following X messages are used, on paper claims only. X-code reject messages X004 X229 X247 X248 X-Code Reject Messages, Paper Claims Only There is missing or invalid information on the claim. X249 Provider/Attending physician information is missing or invalid Alpha prefix missing or invalid X259 Patient relationship is missing or invalid Procedure code/modifier missing or invalid Diagnosis code is missing or invalid X425 Patient/member information is missing or invalid *Current Procedural Terminology 2015 American Medical Association. All Rights Reserved.

67 To verify that a claim for a Wellmark, BlueCard, or FEP member has been received and processed, you may: Check claim status 1) Use Wellmark's Web tools: On Wellmark.com, log in and select Check a Claim for the following information: - where a claim is in the processing cycle - how a claim was settled and the date it was settled - a list of all the pended claims your office or facility currently has with Wellmark - how a claim was adjusted - if coordination of benefits is involved Note: Nonparticipating providers are able to use Check a Claim only to identify whether or not we have received their claims. Online inquiry tool 2) Use Wellmark's online inquiry tool found by: - Selecting the Ask & Track a Question tool on the Provider secure page on Wellmark.com. - Choosing the "Contact Us" link from the Check Member Information or Check a Claim tools in the Provider secure page on Wellmark.com. When you use the link from these tools, pertinent information is prepopulated on your inquiry. 3) Call the appropriate Provider Service area listed on the Service Contacts page of this Guide. Web security access instructions To gain first-time access to our online tools, apply by selecting the Register now link on Wellmark.com > Provider.

68 Practitioners or facilities and Wellmark have 18 months from the date of the original Wellmark remittance on which the original claims in question appear, to request a claim review or submit a change. This 18-month time frame applies to BlueCard claims, and to claims that are overpaid or underpaid. The following information explains the Provider Inquiry and appeal process for claims. Step 1: The Claims Inquiry Process Before you can request a formal appeal on a processed claim, you must first submit a Provider Inquiry. This may be submitted one of three ways: Web-based inquiry Provider Inquiry Form (mail) Provider Service phone call If the inquiry is not resolved to your satisfaction and new or different information is available, you should submit a second inquiry with additional information. When no additional information is available, you may submit a post-service provider appeal. Provide complete and timely information Please provide complete, specific information when requesting a claim review (inquiries or appeals). Wellmark has specific time parameters for submitting such requests, often based on the date of Wellmark's initial remittance. Incomplete information may reduce or eliminate future review options. When submitting a request for a claim review, be sure to provide: The member's correct identification number and name. Specific information that identifies the claim, such as the date of service, total amount submitted, and patient name, or the claim number. The reason for the request. Without this information, it can be challenging for us to identify the claim in question and provide a prompt, proper review. For example, Wellmark may have paid one service on your claim and denied two others as "not a benefit." Without a specific request, we may focus our review on the denied services, when you were expecting a review of Wellmark's maximum allowable fee (MAF) for the paid service. Sample information As long as your instructions are specific, brief information can be sufficient, such as: Review the MAF for surgery, DOS mm/dd/yyyy, using op report. Note that surgery was complicated by.

69 Claim Corrections Which Must Be Submitted in Writing As a general rule, most information can be submitted using the Ask and Track a Question tool or over the phone. This includes changes to FEP and BlueCard claims. Certain corrections, however, must be submitted in writing. A list follows: The claim has invalid or missing information Charges need to be altered Missing written documentation when Medicare is secondary (MSP) Correction to Type of Bill (TOB) when it changes the place of service Coordination of Benefits (COB) Exception: If the other carrier denied services, corrections can be made online or by phone, but we must know why services were denied; i.e., not a covered benefit, patient no longer covered, insufficient information to process the claim. The claim is denied due to a preexisting condition, a ridered condition, or underwriting. To review the claim for possible adjustment, written documentation is required. Workers' Compensation information Exception: FEP Customer Service will take over the phone a provider's statement that Workers' Compensation is not involved. Subrogation information Exception: Medical Pay Exhausted. A statement that the member has exhausted his or her medical benefits by the other carrier will be accepted if the provider is able to supply over the phone a list of claims paid by the other carrier; otherwise, written documentation must be submitted. When to Submit a Provider Inquiry form Provider Inquiry Form Complete a Provider Inquiry form for each inquiry (IA: B-5403; SD: B-3402) when you are: 1) mailing a request to have a previously processed claim adjusted; or 2) attaching additional information for claim review Additional information may include the following: office notes medical records physical medicine/chiropractic notes operative reports information relating to Coordination of Benefits or Workers' Compensation pharmacy -NDC number -quantity -description of service/drug home medical equipment -include provider manufacturer's invoice if requesting additional allowance

70 Complete the "Required Information" fields on the Provider Inquiry form, as well as other information needed to research your request. If a required field is incomplete or left blank, Wellmark will return the inquiry with a cover letter that identifies the information needed. Below are scenarios that address when it is/is not necessary to complete multiple Provider Inquiry forms. Situations that affect Provider Inquiry form submissions Same Situation/Different Wellmark Members Involved If a situation occurs that affects a group of claims (e.g., claims are miscoded), complete a separate Provider Inquiry form for each patient. You may mail these claims together and attach a cover letter that explains the requested adjustment. One Wellmark Member/Same Situation/Multiple Claims If a situation occurs that affects one member but applies to multiple claims (e.g., several claims are denied because it appears that Workers Compensation is involved. At a later date, Wellmark is given information that verifies our responsibility to process the claims under the member s health benefits), submit one Provider Inquiry form and attach copies of the Provider Claim Remittance with each claim circled that was denied in error. One Wellmark Member/Multiple Situations/Multiple Claims If you are inquiring about different situations that involve the same patient, please complete a separate Provider Inquiry form for each situation. Time frame for Provider Inquiry replies Provider Inquiry form examples How to access or order Provider Inquiry Provider Inquiry Form Replies You will receive a written response that explains Wellmark's decision and a copy of the original Provider Inquiry form, usually within two weeks of receipt. The only time you will not receive a letter is if Wellmark determines that an adjustment can be made. Adjustments will appear on your Provider Claim Remittance (PCR). Provider Inquiry Form Examples Examples of the Iowa and South Dakota Provider Inquiry forms are on the next two pages. The submission address is printed at the top of each form. To Access Provider Inquiry Forms The Provider Inquiry form is available at Wellmark.com (Provider > Communication and Resources > Forms). You can type information into the form's fields online, but you will need to print and mail it to the address at the top of the form. If you prefer to have a supply of Provider Inquiry forms in your office, you may order paper copies by completing the Provider Forms Order for your state, available at the top of the Forms page.

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