Claims Reports: Overview Introduction BCBSTX provides explanations of claims handling to you and the patient. There are two reports that may be sent to your office, and they are each described in this section. In this Section This section describes the following claims reports: Report Title Page Provider Claim Summary for CMS 1500 (08/05) Claims E 2 Provider Claim Summary for UB-04 Claims E 7 Explanation of Benefits (EOB) E 11 Page E 1 Rev. 06/25/07
Sample of Provider Claim Summary Rev.06/25/07 Page E 2
Provider Claim Summary for CMS Claims 1-7 Providers receive a Provider Claims Transaction Report listing payments. The following table explains fields 1 through 7 on this report: Field Field Name 1 Document A unique number assigned to each Provider Claims Transaction Report. 2 NPI The NPI number. In a clinic or group practice, the 800,000 number for the provider who performed the service will appear to the right of the patient s name. 3 Patient Name The patient s name as reported to BCBSTX. 4 Patient Account # The patient s account number assigned by the provider as indicated on the claim submitted to BCBSTX. If an account number is not given, this field will be blank. 5 Subscriber Identification The subscriber s identification number from the ID card. 6 Group # The number that identifies the subscriber s group. 7 Claim Type This displays the code for the type of claim. Key for Claim Type Claim type code definitions: Code ADJ CMC COB MC MCP MR REG Definition Adjustment of a Previously Processed Claim Coordination of Benefits with Managed Care Coordination of Benefits Managed Care (optional or no PCP) Managed Care (PCP required) Medicare Primary Regular Business (Indemnity or ParPlan) Continued on next page Page E 3 Rev. 06/25/07
Provider Claim Summary for CMS Claims, Continued 8-12 The following table explains fields 8 through 12 on the Provider Claims Transaction Report: Field Field Name 8 Internal Control A unique number assigned to each claim as it enters the BCBSTX claims processing system. 9 Service Dates The beginning and ending dates of service indicated on the claim. If the claim contains only one date of service, the To field will be blank. 10 POS This indicates the place of service or where the services were performed (e.g., office, inpatient hospital). 11 Type of Service A description of the service(s) rendered. 12 Proc Code The code from CPT or the BCBSTX conversion code used to identify and report the service performed. Note on 11 and 12 The fields for type of service (11) and procedure code (12) will only display for detailed line item charges where there is a difference in the total charge and the contract allowable on claims other than Medicare-related, COB, and Adjustments. Continued on next page Rev.06/25/07 Page E 4
Provider Claim Summary for CMS Claims, Continued 13-16 The following table explains fields 13 through 16 on the Provider Claims Transaction Report: Field Field Name 13 Total Charges The total charges filed on the claim. 14 Contract Allowable The benefits allowed by the subscriber s coverage. 15 MSG Code The message code for the explanation of the difference between the billed charges and the contract allowable for that procedure. Multiple message codes may indicate that the claim was processed with more than one type of coverage or policy. Please see Message Code Explanation (18). 16 Patient s Share Listing of any copayment, deductible, cost share (coinsurance), and charges for medically necessary, limited, or noncovered services. Patient s Share The subscriber is responsible for no other charges submitted on the claim except for the following: Patient s Share Copay/Deductible Coinsurance Other Which Includes The amount of copayment and/or deductible taken from the gross allowable charges. The amount taken from the gross allowable charges and the patient s portion when contract benefit percentages were applied. This includes the patient s benefit contract. Medically necessary items not covered or limited by the patient s benefit contract. Continued on next page Page E 5 Rev. 06/25/07
Provider Claim Summary for CMS Claims, Continued 17-19 The following table completes the key to the Provider Claims Transaction Report: Field Field Name 17 Benefit Payment The benefit amount paid by BCBSTX after any copay, deductibles, cost share, and charges for medically necessary, limited, or noncovered services were deducted for the contract benefit allowable amount. 18 Message Code Explanation of the difference between the billed charge and the contract allowable for that procedure. 19 Totals Totals for each column for all patients included on the report. Rev.06/25/07 Page E 6
Provider Claim Summary for UB-04 Claims 5 COUNTY MEDICAL CENTER P. 0. BOX 123456 YOUR CITY, TX. 12345-1234 ANY MESSAGES WILL BEGIN ON PAGE 1 PROVIDER CLAIM SUMMARY DATE: 02/10/05 1 PROVIDER NUMBER: 0000HH1234 2 CHECK NUMBER: 12345678 3 TAX IDENTIFICATION NUMBER: 123156769 4 *********** INPATIENT PATIENT: HORMAN DOE PATIENT NO: 123456789 ADMIT DATE FROM DATE END DATE CLAIM NO: 0000123456789000X CLAIM TYPE: 01/30/05 01/30/05 01/31/05 GROUP-SUB NO: FEPTX-12345678 HPI: D DRG DAYS DRG PROVIDER OTHER PAYABLE FACILITY ADJUSTED MANAGED CARE TOTAL AMOUNT /TRT CODE CHARGE / WITHHOLD ALLOWABLE PROV. CHARGE DEDUCTION(S) PAID 001 294 $10,816.00 $8,022.01- $2,795.99 $2,795.99 $500.00 $2,195.99 MESSAGES/REASONS: OE, OH, DRG *** DEDUCTIONS/OTHER INELIGIBLE *** CONTRACT DEDUCTIBLE/COPAY: $100.00 MANAGED CARE DEDUCTION(S): $500.00 TOTAL DEDUCTIONS/OTHER INELIGIBLE: $600.00 PATIENT'S SHARE: $600.00 -------------------------------------------------------------------------------- PROVIDER CLAIMS AMOUNT SUMMARY MUMBER OF CLAIMS: 1 AMOUNT PAID: $2,195.99 PROVIDER CHARGES: $10,618.00 RECOUPMENT AMOUNT: $0.00 ADJUSTED PROVIDER CHARGES: $2,795.99 NET AMOUNT AMOUNT: $2,195.99 PATIENT'S SHARE: $600.00 --------------------------------------------------------------------------------- CLAIM TYPE --------------------------------------------------------------------------------- MESSAGES/REASONS: (OE ). A CONTRACT DEDUCT I BLE/COPAY HAS BEEN TAKEN. (OH ). PROGRAM REQUIREMENTS AS IDENTIFIED BY THE MEMBER'S CONTRACT HAVE NOT BEEN FULFILLED. THIS IS THE PATIENT'S LIABILITY. (DRG). THE PAYMENT ON THIS CLAIM HAS BEEN PROCESSED ACCORDING TO THE OMNIBUS BUDGET RECONCILIATION ACT OF 1990. THE PAYMENT PROVIDED IS THE SAME AS THE PAYMENT YOU WOULD HAVE RECEIVED HAD THE PATIENT BEEN ENROLLED IN MEDICARE PART A. THE PAYMENT IS BASED ON THE MEDICARE DRG PRICE. THE SUBSCRIBER IS NOT RESPONSIBLE FOR THE DIFFERENCE. 1 OF 1 Page E 7 Rev. 06/25/07
Provider Claim Summary for UB-04 Claims, Continued 1-9 The Provider Claim Summary (PCS) is a notification statement sent to contracting providers with Blue Cross and Blue Shield of Texas (BCBSTX) after a claim has been processed. The following table explains fields 1 through 9 on this report: Field Field Name 1 Date Date the summary was finalized. 2 NPI NPI 3 Check assigned to the check for this summary. 4 Tax Identification which identifies provider s taxable income. 5 Provider or Group Name & Address The provider/group address where the services were rendered. 6 Patient Name of the individual who received the service. 7 Claim The Blue Cross number assigned to the claim. 8 Group-Sub that identifies the employer group and member. 9 Patient The patient s account number assigned by the provider. Continued on next page Rev.06/25/07 Page E 8
Provider Claim Summary for UB-04 Claims, Continued 10-19 The following table explains fields 10 through 19 on this report: Field Field Name 10 Claim Type Code for type of claim (benefit plan) see field 27. 11 HPI Indicator Blue Cross payment method for this claim. IND DESCRIPTION D DRG B Outpatient DRG Cap W Withhold/Discount R Case Rate E % of charge w/cap F Fee Schedule P Per Diem N Negotiated C Inpatient Case Rate 12 Admit Date Date if admission. 13 From Date Beginning and ending dates of 14 End Date services rendered. 15 Days/Treatment of days/treatment. 16 DRG Code DRG code for this type of service. 17 Provider Charge Total amount of billed charges. 18 Other Payable/Withhold Other payable amounts, such as discounts or withholds, that affect the adjusted provider charges. 19 Facility Allowable The provider s allowed amount according to negotiated contract. Continued on next page Page E 9 Rev. 06/25/07
Provider Claim Summary for UB-04 Claims, Continued 20-29 The following table explains fields 20 through 29 on this report: Field Field Name 20 Adjusted Provider Charges The allowed amount including other payable or withhold. 21 Managed Care Deduction(s) Managed care deductions including penalties, copayments and coinsurance amounts. 22 Total Amount Paid The amount paid to the provider for this service. 23 Contract Coinsurance The coinsurance/deductible amount applied to this claim. 24 Total Deductions/Other Ineligible Total deductions and other ineligible amounts. 25 Patient s Share Amount patient pays. Providers may bill this amount to the patient. 26 Provider Claims Amount Summary Total for claim(s) processed on this summary. 27 Claim Type The description for the type of claim in field 10. Code Definition Blank Traditional/Indemnity M Managed Care S Coordination of Benefits T Managed Care w/coordination of Benefits 28 Messages/Reasons (appears on last page of PCS) 29 Messages/Reasons Description The description for messages relating to: Non covered services Program deductions PPO reductions Rev.06/25/07 Page E 10
Sample of Explanation of Benefits (EOB) Page E 11 Rev. 06/25/07
Explanation of Benefits (EOB) 1-13 The EOB is provided to the BCBSTX subscriber and also to the provider when the subscriber is part of an ASO (Administrative Service Only) group. The table below provides a key to this report. Field Field Name 1 N/A The ASO Account name or the BCBSTX logo. 2 Claim Received On The date the claim was received by BCBSTX. 3 N/A The date the claim was paid. 4 Subscriber The subscriber s name will appear here. 5 Patient The patient s name as reported to BCBSTX on the claim submitted. 6 Subscriber ID The subscriber s identification number from the ID card. 7 Group that identifies the subscriber s group listed on the ID card. 8 Control A unique number assigned to each claim as it enters the BCBSTX claims processing system. 9 Dates of Service The beginning and ending dates of service indicated on the claim. If the claim contains a single date of service, the To column will be blank. 10 Provider Physician s or other provider s name. 11 Type of Service A general description of the service provided. 12 Charges Submitted Amount billed on the claim submitted to BCBSTX. 13 Eligible Charges Amount of charges billed that are allowed under the subscriber s benefit plan. Continued on next page Rev.06/25/07 Page E 12
Explanation of Benefits (EOB), Continued 14a 14e The following table explains field 14a-14e Your Responsibility or the patient s share: Field Field Name 14a Noncovered The amount for any services not covered by the subscriber s benefit plan. 14b Copay Amount of payment the subscriber makes at the time services are provided, if indicated by the subscriber s benefit plan. 14c Deductible The amount of eligible expenses that the subscriber is responsible for before benefits will be available. 14d Cost Share The portion of covered expenses the (Coinsurance) subscriber pays after the deductible has been satisfied. 14e Your Total This is the total amount the subscriber is responsible for based on the charges submitted. This total includes any amounts the subscriber may have previously paid to the provider. 15-16 The table below continues the EOB key: 15 Your Benefit The amount that is payable on the Plan Pays claim submitted to BCBSTX. This is the amount of payment issued to the BlueChoice Network provider. 16 Explanations An alpha code matching a narrative explanation listed at field 18. Continued on next page Page E 13 Rev. 06/25/07
Explanation of Benefits (EOB), Continued 17 21 The table below completes the EOB key: Field Field Name 17 Totals The totals of each of the following columns: Charges Submitted Eligible Charges Noncovered Copay Deductible Cost Share Benefit Plan Pays 18 Explanations: This is a narrative describing claims processing. 19 N/A Deductible/Cost Share/Year-to- Date/Maximum information will be listed here. This is a summary of subscriber liability for cost share and/or deductible, if applicable to this claim. 20 N/A Customer Service address and telephone numbers will be displayed here. Inquiries regarding claims processing would be handled at this address or telephone number. 21 N/A When payment is made, the check is attached here. (One check per ASO subscriber.) Rev.06/25/07 Page E 14