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Provider Information Changes on Electronic and Paper Claims for Patients on Highmark’s System

Date:
October 22, 2021

As your patients move to Highmark’s system, please be aware that the Highmark claims system requires that the billing provider listed on the claim be submitted as the group and not the individual provider. This requirement is necessary because Highmark contracts at the group level. While we currently accept either, you may need to make this change to avoid delays and/or denials for your patients on Highmark’s system. One exception is for sole practitioners; we will continue to accept an individual provider’s National Provider Identifier (NPI) number for billing providers who do not have a Group NPI.

Provider Information on Claims

If the provider who renders the service is part of a provider group or facility and that group or facility is receiving the payment, then the “billing provider” on the claim MUST contain the group or facility information including Name, NPI, Address, and Tax ID. The provider who rendered the service must be billed as the “rendering provider” and the claim must include Name, NPI, and any applicable taxonomy code. Billable groups will continue to list only the group as the billing provider (with no rendering provider).

  • Example: Dr Jane Doe is a member of Provider Group ABC
    • 837 Electronic Billing Guidelines
      • Provider Group ABC submitted in Billing Provider Loop 2010AA
      • Dr. Jane Doe submitted in Rendering Provider Loop 2310B
    • CMS1500 Paper Billing Guidelines
      • Provider Group ABC submitted in Billing Provider Box 33
      • Dr. Jane Doe submitted in Rendering Provider Box 24J

ASK Submission Guidance

When submitting electronically to Administrative Services of Kansas (ASK), we are recommending you adopt industry standards that have not always been enforced in our system, but are likely to be required in the future. This will help us process your claims quickly and avoid denials and rejections. As we adopt Highmark’s claims edits, please ensure your claims are HIPAA Standard-compliant:

  • 837I (Institutional Claims)
    • Billing and service facility U.S. addresses must contain a valid 9-digit ZIP code; we will no longer accept the last 4 digits as “0000”
    • Admitting physicians must be included on all claims other than non-scheduled transportation claims
    • Operating physician must be submitted when a surgical procedure code is listed on the claim
    • When submitting an interim bill, the discharge status must be “30” indicating the member is still a patient
    • Unless exempt, “Present on admission” indicators are required on inpatient claims
    • A procedure code description is required when the procedure code is “Unlisted”
  • 837P (Professional Claims)
    • Billing and service facility U.S. addresses must contain a valid 9-digit zip code; we will no longer accept the last 4 digits as “0000”
    • Procedure code description is required when the procedure code is “Unlisted”
    • Admission date is required for inpatient claims
    • Anesthesia-related procedure codes submitted must be valid surgery codes
    • Service line dates of service must be greater than or equal to the submitted hospital inpatient admission date

For more information about the Highmark affiliation, please visit our provider resource page by clicking below.

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