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Provider and Facility Reference Manual

Section 13 - Claims and Billing

Federal Deficit Reduction Act (DRA) of 2015 and Fraud, Waste and Abuse


Health care organizations subject to Section 6032 of the federal Deficit Reduction Act of 2005 (the “DRA”) are required to educate their providers and contractors about the False Claims Act as well as the organization’s policies and programs for detecting and preventing fraud, waste and abuse. The following documents are intended to satisfy Highmark Blue Cross Blue Shield of Western New York’s obligations under the DRA.

We know you share Blue Cross Blue Shield’s goal of ensuring that all clinical and business activities are conducted in full compliance with applicable laws and government program requirements. Accordingly, we look forward to your cooperation in applying Blue Cross Blue Shield’s fraud prevention and detection policies and programs in connection with the services you provide to our members.

If you have any questions regarding these documents, please do not hesitate to contact Blue Cross Blue Shield’s fraud prevention program at 716-887-8451 or 1-800-333-8451.

Electronic Billing


Electronic claim submission is an easy way to minimize the amount of time it takes your claim to reach and be processed by the health plan. Submitting claims electronically will also save you money by reducing what you spend on orders for paper claims and high postage fees.

Blue Cross Blue Shield contracts with Administrative Services of Kansas, Inc. (ASK) to be our vendor for this service. ASK will receive all provider claims submissions and will perform any necessary edits to ensure the claims meet all regulatory and contract requirements. The claims will then be transferred to the health plan for adjudication and payment.

ASK was selected because of their experience and credibility in the Electronic Data Interface (EDI) marketplace. We have chosen this company to be our partner in achieving the electronic transaction component of HIPAA.

Enrolling with ASK

To obtain information on or sign up for Electronic Claims Submission with ASK, please visit their website, located on the Internet at ask-edi.com.   Click on “Getting Started” on the menu bar.

Please fill out the online form completely to register and click ‘Submit’. If you would like to contact ASK by phone, please call their toll free number at 1-800-472-6481; press option 1 for New York Customers and select option 1 again to connect to an EDI Helpdesk specialist.

Click the ‘Resource Center’ tab for:

  • Payer News
  • General Information
  • CAQH-CORE Operating Rules
  • ANSI Testing Guidelines for Batch Transactions

Acceptable Claim Formats

ASK accepts and edits electronic claims submissions using the following formats:

  • ANSI X12 837P 5010 based on the HIPAA Implementation Guides (Professional)
  • ANSI X12 837I 5010 based on the HIPAA Implementation Guides (Institutional)

Providers receive a clearinghouse response report for each electronic submission that indicates:

  • Whether we have received the file
  • The number of claims submitted successfully
  • The data fields that need to be corrected before electronically resubmitting a claim returned for edit errors

Changes in Claims Routing Services

Medicare Primary Claims Routing
In the past, we have routed Medicare Primary claims as a courtesy. This service is no longer available when submitting claims to our clearinghouse.

Please contact Medicare's Electronic Media Communications Department, at 1-607-766-6000, as soon as possible to set up your system for direct submission of these claims to Medicare.

Other Payer Claims Routing

When you enroll with ASK, you will be offered a one-year free trial membership to ASK's commercial clearinghouse, EDI Midwest. This offer provides you with the option of clearing other payers' claims through ASK. EDI Midwest routes claims to 800 payers around the nation.

EDI Midwest will only accept claims that can be sent to their final destination electronically. Your ASK EDI Account Representative can give you more detailed information about EDI Midwest at the time you enroll to submit your claims to ASK. You can contact ASK directly at 1-800-472-6481.

If you elect not to use the services of EDI Midwest, please make arrangements with your current clearinghouse vendor or submitter to have non-Blue Cross Blue Shield claims submitted directly to the appropriate payer.

We will continue to process claims destined for our vendors and all of our lines of business including: Non Direct-Bill ITS/BlueCard, Express Scripts, and Federal Employee Program (FEP).

Non-Electronic Claim Forms

Non-electronic claims should be submitted using the approved CMS-1500 or UB-04 claim form. Please note that all required fields of the claim form must be completed, or the claim may be returned for additional information. These forms can be purchased from your forms vendor

National Provider Identifier (NPI)

We require the submission of the provider's Billing NPI number and not the 12-digit provider number on the claim form. Mail all claims, (Local, Indemnity, and Managed Care, including Senior Blue HMO and BlueSaver plans), to:

Highmark Blue Cross Blue Shield of Western New York
P.O. Box 80
Buffalo, New York 14240-0080

Federal Employee Program (FEP):
Highmark Blue Cross Blue Shield of Western New York
Attention: FEP Department
P.O. Box 80
Buffalo, New York 14240-0080

To improve accuracy and timeliness of paper claim submissions, we utilize Optical Character Recognition/Intelligent Character Recognition (OCR/ICR). To maximize the efficiency of this technology, we are asking providers who submit paper claims to use the red CMS 1500 (2-12) or UB-04 standard claim forms.

Please note: Edits for electronic claims and paper claims are exactly the same. Submitting a paper claim that originally rejected electronically without fixing the problem will only lead to a rejection of the paper claim as well.

All claims for Medicare covered services and items that are the result of physician’s order or referral shall include the ordering/referring physician’s name, NPI, and taxonomy code in boxes 17, 17a, and 17b of the CMS 1500 claim form.

The following services/situations require the submission of the referring/ordering provider information. This is not an all-inclusive list:

  • Medicare covered services and items that are the result of a physician's order or referral
  • Parenteral and enteral nutrition
  • Immunosuppressive drug claims
  • Hepatitis B claims
  • Diagnostic laboratory services
  • Diagnostic radiology services
  • Portable x-ray services
  • Durable medical equipment
  • When the ordering physician is also the performing physician (as often is the case with in-office clinical laboratory tests)


Claim Submission Tips

  • Use the red CMS 1500 or UB-04 claim forms.
  • Check your printer to ensure that your ink is dark.
  • Do not highlight data on the claim form.
  • Check your printer to ensure that it is lined up with the fields on the claim form.
  • If the information submitted is incorrect or missing, we may generate a letter asking you to resubmit the claim with the correct information.
  • The use of any other type of CMS1500 or UB-04 claim forms other than the red forms will delay processing.
  • Paper claims must have a physical address in box 33; if a PO Box is submitted, the claim will be returned for correction and resubmission.
  • ZIP codes must be submitted with 9 digits
  • Include the referring/ordering physician NPI as required by CMS billing requirements.

Timely Filing

As of November 1, 2021 all claims must be submitted to Blue Cross Blue Shield within 365 days from the date of service. Claims that are submitted after 365 days will be denied. The calculation begins from the date of service, discharge date or last date of treatment up to 365 days, including weekends. Do not delay the billing of a claim for any reason.

If a claim denies for timely filing and you have previously submitted the claim within 365 days, resubmit the claim and denial with your appeal. Listed below are the guidelines for submitting appeals.

Timely Filing Does Not Apply To:
 

  • Early Intervention Providers – There is no time limit
  • Workers Compensation
  • VA Hospital and Providers – 72 months timely filing

Submitting Appeals

Submit all timely filing appeal requests in writing, stating the reason for the delay of submission beyond 365 days. The claims you are appealing must be on paper and attached to your appeal. Please keep copies of the information you send for ease in identifying claims that will be approved/denied.

Electronically Submitted Claims:
For electronic claims that have not been processed, please submit one of the following reports with your appeal request and claim(s):

  • Deleted Claim Edit Report
  • Clearinghouse Response files

If you would prefer to receive these reports instead of your vendor, please contact ASK at 1-800-472-6481.

If you are using the electronic response file to do automatic posting of errors or claims accepted, the following information needs to be included on the report you send to us:

  • Error record
  • Record sequence
  • Error code
  • Clearinghouse messages
  • Error field
  • Error description

Continue to balance your submission counts to those on the Clearinghouse Response file. If a discrepancy exists between the counts, notify our Help Desk immediately. The Clearinghouse Response file will be the only notification you will receive about a claim deleted in the transmission.

If you currently do not receive any of the above reports or experience discrepancies on claim counts, contact ASK at 1-800-472-6481.

Clearinghouse Rejections

If a claim rejects in the clearinghouse (i.e., invalid member identification number), submit your deleted claim edit report and claim with your appeal.

Coordination of Benefits (COB)

If an insurance carrier other than Blue Cross Blue Shield is the primary carrier, then providers must submit the other carrier's payment voucher and claim within three months of the payment from the other carrier. COB claims can be submitted using the 837I or 837P. Providers do not need to submit the other carrier explanation of benefits (EOB) if all of the information is submitted on the 837.

If a provider is receiving an 835 (electronic remittance), they may or may not have a paper voucher or EOB to submit to Blue Cross Blue Shield. The information received on the 835 should be incorporated into the secondary fields on the 837.

Incorrect Insurance Information

If the member provided incorrect insurance information, the denial notice from the other carrier must be submitted with the original claim within three months of the other carrier's denial.

No Coverage

If a participating provider, in dealing with a patient finds that he/she has no insurance, the member should be asked to sign and date a patient responsibility form or waiver.

A provider may seek payment from the patient for any services provided.

If the member realizes that he or she has Blue Cross Blue Shield coverage after a provider has billed the member and the claim is beyond the twelve month timely filing limit, the provider should submit the signed waiver/patient responsibility form and claim with your appeal. Do not re-bill the member.

If you do not have a signed waiver, submit copies of billing statements with your claim(s) and appeal that indicates that you have billed the member who has now advised you that he/she has Blue Cross Blue Shield insurance.

Member Held Harmless

Participating providers are responsible to abide by the stipulations of the Blue Cross Blue Shield provider agreements. In cases where services were not billed to us within the timely filing limits, you cannot bill the member directly. The member is to be held harmless. The reimbursement issue is between you as a participating provider and us as the insurer. You may file the claim late with a request to waive the limit with an explanation. Upon review of your appeal, approval or denial will be determined. However, at no time is the member to be held responsible.

Filing Requirements for Members and Non-Participating Providers

Claims submitted by members or non-participating providers (for traditional and approved services through our managed care contracts) must be submitted within the following time frames:

  • Dental: 24 months
  • Major Medical: 12 months
  • Traditional: 12 months
  • Managed Care: 12 months

If claims, requests for adjustments, appeals or claim reviews are submitted by the member or a non-participating provider after the above time frames, the claim will be denied. The non-participating provider can bill the member for these denied claims.

Claim Adjustment Policy

We’ve updated our claims adjustment policy. Effective January 1, 2022, you will have 365 days from the date of service or date of discharge (for inpatient claims) to request an adjustment on a claim or to submit any corrections for your Legacy and Highmark system patients. 

For example, if a claim has a date of service August 1, 2022, you will have until July 31, 2023 to submit an adjustment request on that claim. 

Exclusions to this Policy
 

  • Claims investigated as part of an internal audit for fraud, waste or abuse are exempt from this policy and are subject to payment recovery.
  • Coordination of Benefits (COB) and Other Party Liability (OPL) situations are exempt from this policy. Consideration of claims/adjustments will be based on current COB/OPL timely filing guidelines. In the case of No Fault and Other Insurance situations, submissions and adjustment requests must be received within 365 days of the other carrier's process date. Claims that are related to Workers' Compensation are not subject to timely filing limitations.

Claims Submission for Medicare Supplemental Contracts Medicare Part B

Medicare Supplemental contracts are designed to accompany traditional Medicare coverage. Claims must be submitted to Medicare first for processing. Claims processed by the Upstate Medicare Part B Division with one or more lines approved to pay are sent to Blue Cross Blue Shield electronically on the Medicare Crossover Tape. Blue Cross Blue Shield processes the balance for members who have a Community Blue 65 Rider, Traditional Over 65 and Medigap coverage. Medicare balances are paid directly to our participating providers, regardless of whether or not the provider accepts assignment with Medicare. Payment is sent to the member if the provider rendering the service does not participate with Blue Cross Blue Shield.

Auto/National Accounts Exception

The exception to the above is for members that have coverage through our Auto/National contracts. We will continue to reimburse providers based on their participation with Medicare for these members. If you participate with Medicare, your covered balances will be sent directly to you from Blue Cross Blue Shield. If yes (EOMB)

When a Medicare Part B claim is transferred to Blue Cross Blue Shield for processing, the Explanation of Medicare Benefits (EOMB) will state: "This claim has been forwarded to the appropriate complementary insurer." If this message appears, do not submit a paper claim to us. However, if this message does not appear and the patient is covered by Community Blue 65 Rider, Traditional Over 65 or Medigap, send us a completed, approved claim form

If the claim does not electronically transfer to Blue Cross Blue Shield, this may indicate that the Medicare Identification Number on our files does not match the number on Medicare's files. To assure that claims for this patient are electronically transferred in the future, notify our Customer Service Department so we can investigate and update our membership files. Claims that are not electronically transferred to Blue Cross Blue Shield can be submitted electronically or by paper.

Medicare Part B claims can be submitted using the 837I or 837P. Providers do not need to submit the EOMB if all of the information is submitted on the 837. If a provider is receiving an 835 (electronic remittance), they may or may not have a paper voucher or EOMB to submit to Blue Cross Blue Shield. The information received on the 835 should be incorporated into the secondary fields on the 837.

Please submit claims only if they have not been transferred to us on the crossover tape to:

Highmark Blue Cross Blue Shield of Western New York
P.O. Box 80
Buffalo, New York 14240-0080

New York State Prompt Pay Interest

Prompt Pay Interest exceeding $1.99 per claim is generated on a daily basis for claims not processed within 30 days of Blue Cross Blue Shield's receipt of the claim. Checks and wire payments are issued more frequently than the weekly cycle to ensure that prompt pay requirements are met. Any interest paid appears under the "Interest Paid" column on your payment voucher.

Claims submitted for adjustment due to errors caused by Blue Cross Blue Shield processing receive prompt pay interest.

The following are excluded from prompt pay interest:

  • Administrative Services Only (ASO) & Administrative Services for National Accounts (NSO) contracts
  • Federal Employee Plan (FEP) contracts
  • Services rendered by out-of-state providers
  • Senior Blue and BlueSaver claims from non-participating providers
  • National Accounts, when an out-of-state Plan, is the control Plan
  • Blue Card claims for Members from Plans outside New York State, home and host

If you are a capitated provider billing for fee-for-service procedures, prompt pay interest will be calculated for those claims, if necessary.

Coordination of Benefits (COB)

Coordination of benefits applies to members who have more than one group health insurance contract. Blue Cross Blue Shield coordinates benefit payments with other carriers to ensure members receive all of the benefits to which they are entitled and to prevent duplicate payments. Other insurance information should be verified each time that a patient visits your office.

Preauthorization and Referral Requirements

For managed care (including POS in-network claims), all preauthorization/referral policies and procedures apply, even though Blue Cross Blue Shield may be the secondary payer.

For Preferred Provider Organization (PPO) contracts, all preauthorization policies and procedures apply, even though Blue Cross Blue Shield may be the secondary payer.

Preauthorization is not required for patients with Medicare as their primary insurance.

If appropriate preauthorization of services has not been made, or if a valid referral has not been issued before processing a claim, we may deny payment even on a secondary basis if the services are determined not to be medically necessary.

Primacy

When a patient is covered by two or more health insurance plans, one plan is determined to be primary and its benefits are applied to the claim. The following rules apply when determining which carrier is primary:

  1. If one policy does not have a COB provision, then it will be primary.
  2. If the patient is covered under one policy as the employee and under another policy as a dependent, the policy which covers the patient as an employee will be primary.
  3. The primary policy for children is the policy of the parent whose birthday (month and day) falls earlier in the year. If both parents have the same birthday, the policy that covered the parent longer is primary.
  4. When there is more than one insurance policy and the parents are divorced or separated, the rules of primacy vary depending on the court decision.
  5. If the patient is the policy holder and covered under one of the policies as an active employee, neither laid off nor retired, and also covered under another policy as a laid off or retired employee, the policy covering the patient as an active employee will be primary.
  6. If none of the above applies, then the policy that has covered the patient for the longest time will be primary.

Submitting Claims for Secondary Reimbursement

Claims must be submitted electronically in the 837P or 837I format, or on paper using a CMS 1500 or UB-04. All line items billed to the primary carrier should be submitted on the secondary claim.

Attach a copy of the primary carrier's Explanation of Benefits Statement and indicate balance due. The balance due is the amount to be considered by Blue Cross Blue Shield or the patient's responsibility.

Attach a copy of the primary carrier's Explanation of Benefits Statement. Claims submitted on paper without the Explanation of Benefits Statement, will be rejected.

Managed Care Claims

When a claim for managed care (including POS in-network) services is secondary, the benefits of the member's Blue Cross Blue Shield contract will be reduced so that the total benefits payable under the other policy and under the contract we provide to the member do not exceed the amount we would have paid if we were primary.

Traditional Claims

When a claim for Traditional, PPO or POS out-of-network services is secondary, our payment will not exceed our allowance for the services. Also, the sum of the primary and secondary payments will not exceed the provider's charge.

Bill Your Usual Charge

Regardless of our allowance for a service, you should always bill your usual charge. This is beneficial in several ways:

  1. It enables us to determine average charges for procedures.
  2. By using one charge to bill all insurance companies, the chance of billing errors is reduced.
  3. If more than one insurance company has liability for a claim, your standard charge eliminates confusion and helps to ensure proper payment.
  4. Professional Courtesy - No reimbursement will be provided to a provider billing for professional services rendered to his/her immediate family, regardless of whether the family member has coverage under a Blue Cross Blue Shield contract. Immediate family is defined as the provider’s spouse, children, parents and siblings. Blue Cross Blue Shield will not reimburse for services that would normally have been furnished without charge

Submitting Claims for Secondary Reimbursement

Claims must be submitted electronically in the 837P or 837I format, or on paper using a CMS 1500 or UB-04. All line items billed to the primary carrier should be submitted on the secondary claim.

Attach a copy of the primary carrier's Explanation of Benefits Statement and indicate balance due. The balance due is the amount to be considered by Blue Cross Blue Shield or the patient's responsibility.

Attach a copy of the primary carrier's Explanation of Benefits Statement. Claims submitted on paper without the Explanation of Benefits Statement, will be rejected.

Managed Care Claims

When a claim for managed care (including POS in-network) services is secondary, the benefits of the member's Blue Cross Blue Shield contract will be reduced so that the total benefits payable under the other policy and under the contract we provide to the member do not exceed the amount we would have paid if we were primary.

Traditional Claims

When a claim for Traditional, PPO or POS out-of-network services is secondary, our payment will not exceed our allowance for the services. Also, the sum of the primary and secondary payments will not exceed the provider's charge.

Bill Your Usual Charge

Regardless of our allowance for a service, you should always bill your usual charge. This is beneficial in several ways:

  1. It enables us to determine average charges for procedures.
  2. By using one charge to bill all insurance companies, the chance of billing errors is reduced.
  3. If more than one insurance company has liability for a claim, your standard charge eliminates confusion and helps to ensure proper payment.
  4. Professional Courtesy - No reimbursement will be provided to a provider billing for professional services rendered to his/her immediate family, regardless of whether the family member has coverage under a Blue Cross Blue Shield contract. Immediate family is defined as the provider’s spouse, children, parents and siblings. Blue Cross Blue Shield will not reimburse for services that would normally have been furnished without charge

Payment Voucher

Payment vouchers include a detailed explanation of each claim by line of service. Online vouchers are available via a web application by enrolling for this service at Payspanhealth.com. Participating provider summary checks are distributed weekly. Summary checks include payment for claims that finalize during the week's processing. Additional checks will be issued on a daily basis to ensure prompt pay requirements are met.

Electronic transfer of funds is also available by enrolling for this service at Payspanhealth.com. Checks are attached to a simplified summary statement that identifies the total number of claims processed, total services processed and paid, adjustments, and withdrawn payments.

Enrollment in our online voucher is mandatory for all providers, and enrollment in EFT payment programs is mandatory for all facility providers.

Blue Cross Blue Shield has implemented HIPAA compliant Claim Adjustment Reason Codes per the HIPAA 835 Electronic Remittance Transaction standard. Placing the adjustment codes as the first characters in the EX code description will also allow providers to cross-reference electronic remittance with their paper vouchers.

The complete list of Claim Adjustment Reason Codes can be found at the Department of Health and Human Services website.

To receive an Electronic Remittance Advice (835), register with Administrative Services of Kansas (ASK) at www.ask-edi.com. Click “Getting Started” on the menu bar. Please fill out the online form completely to register and click ‘Submit’.

Claim Inquiries and Adjustments


Provider Claim Inquiry Form

The Electronic Provider Inquiry transaction via HEALTHeNET or the Provider Claim Inquiry Form should be used to submit provider appeals, inquiries and adjustment requests for all Blue Cross Blue Shield lines of business. Adjustment requests should be submitted within 180 days from the original claim process date.

Instructions for use of the Provider Inquiry application are available on the HEALTHeNET website.

The Provider Claim Inquiry Form is available on the Forms page of our provider website.

 

Coding Changes

When requesting an adjustment to change a procedure code, please submit with medical documentation substantiating the change. Adjustments received without supporting documentation will be returned to the provider.

Billing with correct procedure and diagnosis codes not only promotes accurate and timely reimbursement, it also supplies critical data which is used to create provider profiles and establish practice patterns.

Overpayments

If your claim is overpaid, please request an adjustment by submitting a Provider Claim Inquiry Form and a copy of the payment voucher that lists the payment. The overpayment will be withdrawn from a future payment. Please do not refund any overpayment to us by check.

Negative Balance

A negative balance (or an accounts receivable, i.e., AR) is a financial balance that is unresolved and owed to Blue Cross Blue Shield as a result of a claim adjustment that has not yet been offset. A voucher reduction is not the same as a withdrawal from a bank account. If you do not have a payment to offset a down adjustment, this will result in a negative balance.

Blue Cross Blue Shield does not withdraw monies directly from bank accounts belonging to provider practices when negative balances occur.

Examples of Overpayments:

Blue Cross Blue Shield reviews claims for accuracy and requests refunds if claims are overpaid or paid in error. Providers also may identify overpayments and bring them to our attention. Some common causes of overpayments are:

  • Post payment review
  • Coordination of benefits
  • Allowance of overpayments
  • Rate adjustments
  • Provider billed in error
  • Duplicate claim submission
  • Non-covered services
  • Claims editing
  • Changes in eligibility

Blue Cross Blue Shield-identified negative balance:

When refunding Blue Cross Blue Shield on a claim overpayment that we’ve requested, please return the negative balance request letter and ensure that this is included with your payment for prompt offset.

Providers and facilities may also request recoupment by transferring their negative balance to an active provider ID number and signing the “Request to Resolve Provider Negative Balance” form on the ‘Forms’ page of our provider website. Please fax it to the number indicated on the form. (Note: this is a dedicated fax number for immediate recoupment notification and should not be used to submit disputes or any other inquiries.)

 Providers and facilities direct disputes of amounts indicated on the negative balance request letter to the address indicated, or contact the phone number on the letter. Please note that the plan may recover the unresolved overpayment through remittance adjustment or other recovery action.

Provider- and facility-identified overpayments (“unsolicited”):

If Blue Cross Blue Shield is due a refund as a result of a negative balance and you have not yet been notified but would like to clear this balance, refunds can be made by completing and submitting a refund check with supporting documentation outlined below. You may also provide an active provider ID in which to transfer the negative balance by using the “Request to Resolve Provider Negative Balance” form on the ‘Forms’ page of our provider website.

While submitting your refund, please include the following information:

  • Provider ID
  • Voucher date of negative balance
  • Contact number of the provider’s office, in case there are any questions

General reminders:
If you carry forward a credit balance for 90 days, Blue Cross Blue Shield may send a letter requesting a refund to clear the credit balance.

Blue Cross Blue Shield may not be able to credit your remittance without sufficient information. When returning an overpayment, please use the “Request to Resolve Provider Negative Balance” form on the  ‘Forms’ page of our provider website.

Provider Support Tools

Blue Cross Blue Shield has created a variety of tools to help the staff in providers' offices understand our contract benefits, claim submission procedures and medical policies. Some of the tools available for your use are:

HEALTHeNET

HEALTHeCOMMUNITY™ Portal is an online community health information network established by an independently incorporated coalition of health insurance plans, including Highmark Blue Cross Blue Shield of Western New York, and hospital providers.

The standard set of transactions available online are as follows:

  • Eligibility Transaction (270/271)
    The eligibility transaction gives offices a direct connection to membership files and allows providers to confirm patients' eligibility in just minutes.
  • Claim Status Transaction (276/277)
    This feature allows you to check the status of your claims, eliminating the need to contact the Provider Service Department.
  • Direct Access to Referrals (278)
    This transaction will allow you to submit/inquire/update referrals for your patients.

Transactions created through the HEALTHeNET application constitute standard ANSI X12 transactions as defined and regulated by the HIPAA mandate (see 45 CFR Parts 160 and 162 - Standards for Electronic Transactions).

Electronic Provider Inquiry

This application allows users to submit inquiries electronically, including attachments.  The payer will respond to these inquiries electronically as well.

To Sign Up for HEALTHeNET:

  • Visit wnyhealthenet.com
  • Click on the 'Sign Up' tab at the top of the HEALTHeNET home page.
  • Complete the online enrollment form. A representative will contact you within five business days of your request to provide further instructions and schedule training.

Provider Pending Claims Status Report

A weekly report identifies claims that we have received and are pending. The following codes are used within the report to identify claims status.

ADJ    Adjustment received, pending final disposition
AMI     Claim received, awaiting additional medical information
COB   Claim received, COB external information requested
PFD    Claim received, pending final disposition
RMN   Claim received, reviewing for medical necessity

Used in conjunction with your payment vouchers, this report enables you to determine if   Blue Cross Blue Shield has received your claim. If a claim is not listed on the Status of Pending Claims Report or on your payment voucher within 30 days after submission, please submit a new claim electronically. Please do not write "rebill" or "resubmission" on paper claims since this will delay processing.

Physician Patient Roster

The Blue Cross Blue Shield Physician Patient Roster is available on our secure website. This is a monthly report to PCPs to help them identify which of their patients are managed care members and provides physicians with other valuable information including:

  • Which patients have chosen them as their PCP
  • Member copay and type of contract
  • Member prefix and suffix

Physicians should use this list to verify patients who have selected them as their PCP.

Coding and Modifiers

Accurate and exact coding is required for appropriate reporting and processing of claims.

Modifiers identify situations inherent to a procedure. Use modifiers to ensure accurate claims processing.

Adhere to CPT and HCPCS coding guidelines when using modifiers to ensure accurate claims processing. Please refer to your CPT/HCPCS books for the most current codes and modifiers.

Tip for coding additional diagnosis (all chronic conditions):

Providers can use code 99080 (Special Reports) to submit additional claim lines with zero charges, if necessary, in order to accommodate the need to send additional diagnosis codes.

Early Intervention Services (EIS)

Early Intervention Services (EIS) Therapy claims must include the TL modifier on the claim in the first position. Therapy services that are billed without the TL modifier will not be identified as an EIS-specific claim and may result in the claim being denied or paid incorrectly.

Clinical Edits / Incidental Denials

Blue Cross Blue Shield uses a vendor-supplied application within our claim processing system, ClaimsXten (CXT), to identify possible unbundled coding and incidental procedural relationships. ClaimsXten automatically analyzes all provider claims for appropriate billing. This includes editing the information submitted on a claim in relation to itself and other claims in a member’s claims history. ClaimsXten helps reduce post-payment audits and adjustments. The logic in the ClaimsXten application is based on Current Procedural Terminology (CPT) and Healthcare Common Procedure Systems (HCPCS) coding guidelines (including the appropriate use of modifiers), analysis of standard medical and surgical practices including review of current coding practice and Blue Cross Blue Shield’s medical policies as well as, but not exclusively, Centers for Medicare and Medicaid Services (CMS) Procedure to Procedure (PTP) standards.

Line item denials on a claim with explanation codes that begin with a lower case letter (alpha), e.g., e31, fc2, are created by ClaimsXten (these translate to Claim Adjustment Reason Code 97 on an 835).  Payment for these codes is subsumed by the payment for the codes to which they are considered incidental or into which they are bundled.

ClaimsXten also identifies “No Separate Fee” (NSF) codes. NSF codes are those considered incidental to/bundled with other reported codes and/or are not considered to add significant additional time, cost, or complexity to the other codes being reported.  NSF logic helps reduce post-payment audits and adjustments. NSF logic is based on CPT and HCPCS coding guidelines (including the appropriate use of modifiers); analysis of standard medical and surgical practices including review of current coding practice; Blue Cross Blue Shield’s medical policies; and Medicare’s payment standards (i.e., status B codes, status P codes, status T codes).

NSF line item denials on a claim will appear with various explanation codes, with the most common being e26, g28, BK2 and MK2 (these translate to Claim Adjustment Reason Code 97 on an 835). Payment for these codes is subsumed by the payment for the codes to which they are considered incident/into which they are bundled.

All ClaimsXten and NSF edits are applied to claims after contract pricing is applied.

The ClaimsXten and NSF logic is updated at least quarterly to acknowledge any additions, deletions, and/or changes to guidelines, policies, and standards.

Clinical edits are available on our secure provider website using our Clear Claim Connection clinical edit search application. NSF edits are available on our secure provider website via the Code & Comment tool.

Routine Services for Qualifying Clinical Trials

Routine services for (or associated with) qualifying clinical trials are eligible for coverage. The standard edits will apply including, but not limited to: preauthorization, unbundling, investigational, and contract in effect at the time of service. The item, device, drug or service that is the focus of the trial is not covered and will be rejected as investigational if billed to Highmark Blue Cross Blue Shield of Western New York.

All Medicare Advantage (Senior Blue, BlueSaver and Medicare PPO claims related to clinical trials should be submitted to original Medicare. Only secondary balances should be submitted to Blue Cross Blue Shield, as these claims will not automatically cross over from Medicare.

Billing for Patients Participating in Clinical Trials


ICD-10 Diagnosis Requirement

List diagnosis code on each service related to the clinical trial to indicate the member is participating in a clinical trial. You must include all appropriate clinical trial codes and modifiers.

The following are the diagnosis codes to be used for submitting claims/authorizations:

ICD10 effective Oct. 1, 2015
Z00.6 (Encounter for examination for normal comparison and control in clinical research program. 

HCPCS

S9988 services provided as part of a phase I clinical trial
S9990 services provided as part of a phase II clinical trial
S9991 services provided as part of a phase III clinical trial

One of the above HCPCS codes must be included as a one-line entry on each claim with $0.00 indicated for the charge. These codes are informational and not separately reimbursed.

Modifiers

One of the following modifiers needs to be indicated on each clinical trial service:
Q0 -Investigational clinical service provided in an approved clinical research study.

The Q0 modifier is used for the item, device, drug or service that is under investigation in the clinical trial or for services unique to the trial requirements, such as data collection.

Q1 -Routine clinical service provided in an approved clinical research study.

Routine services related to qualifying clinical trials submitted with a modifier have potential for coverage. However, if the modifier indicating the routine service is a part of a qualifying trial (Q1) is not documented, the service will be considered investigational as part of a non-qualifying trial, and therefore not eligible for payment.

Use of these modifiers attests to the services being performed in qualifying clinical trials.

Condition code 30 - Available for inpatient claims to indicate the admission includes qualifying trial services.

It is expected that we will not be billed for any services related to non-qualifying trials or for anything provided free of charge by trial sponsors.