Medicare Crossover Claims Submission Reminder
(Updated May 19, 2014)
Blue Cross and Blue Shield Plans have been using the Centers for Medicare and Medicaid Services (CMS) crossover process to receive Medicare primary claims since January 2006. The CMS crossover process routes Medicare Supplemental claims (Medigap and Medicare Supplemental) directly from Medicare to BCBSMT so that providers do not need to also submit the claim to BCBSMT. Over the years, this Medicare crossover process has helped increase efficiency by requiring one claim submission, reducing duplicate submissions, improving payment accuracy, and increasing member and provider satisfaction.
Although the above process is clear, providers have continued to submit the claim to both Medicare and BCBSMT resulting in duplicate claims. These duplicate claims result in additional, unnecessary work and possible inaccurate claims processing, which in turn has a negative impact on providers, members and Plans.
When the Home Plan receives a Medicare Primary claim before it is crossed over, it may be incorrectly paid based on an estimated Explanation of Medicare Benefits (EOMB). Provider payment should be calculated based on the actual EOMB. Members are also impacted when providers submit duplicate claims. When the Home Plan uses an estimated EOMB, they may incorrectly calculate member cost sharing.
In an effort to improve the Medicare crossover administrative process, all providers are instructed to follow new rules concerning Medicare secondary claim submission. When a claim has been crossed over, providers are to wait 30 calendar days from the initial Medicare remittance date before submitting the claim to BCBSMT.
As a reminder, effective Oct. 13, 2013, claims received on or after that date could potentially be impacted. BCBSMT will reject provider submitted claims when Medicare is considered primary including those with Medicare exhausted-benefits that have crossed over if they are received within 30 calendar days of the initial remittance date or with no Medicare remittance date. It is expected that this modification will address duplicate claim submissions.
How do I submit a claim when Medicare is primary and Blue Plan is secondary?
- Submit claims to your Medicare carrier when Medicare is considered primary and the Blue Plan is secondary.
- When submitting the claim, it is essential that you enter the correct Blue Plan name as the secondary carrier. This may be different from the local Blue Plan. Check the member’s ID card for additional verification.
- Be sure to include the alpha prefix as part of the member number. This alpha prefix is located on the members ID card as the first three characters. The alpha prefix is critical for confirming membership and coverage, and if not provided, may delay payments.
When you receive the remittance advice from Medicare, determine if the claim has been automatically forwarded (crossed over) to the Blue Plan:
- Remark codes MA18 or N89 on the Medicare remittance will indicate that the claim was crossed over. The claim has been sent on your behalf to the appropriate Blue Plan for processing. You do not need to resubmit that claim to BCBSMT.
- If the remittance indicates that the claim was not crossed over, submit the claim to BCBSMT with the Medicare remittance advice.
- In some cases, the member ID card may include a Coordination of Benefits Agreement ID number. If so, be certain to include that number on your claim.
If you have any questions or need to request the status of a claim, inquiries should be submitted in the following manner:
- Electronically – send a HIPAA transaction 276 (claim status inquiry) to BCBSMT through your preferred online vendor portal.
- By phone – call our Interactive Voice Response (IVR) automated phone system at 800-447-7828.
When should I expect to receive payment?
The claims you submit to the Medicare carrier will be crossed over to the Blue Plan only after they have been processed by the Medicare intermediary. This process may take approximately 14 business days to occur. This means that Medicare will be releasing the claim to the Blue Plan for processing about the same time you receive the Medicare remittance advice. As a result, upon receipt of the remittance advice from Medicare, it may take up to 30 additional business days for you to receive payment or instructions from the Blue Plan.
What should I do in the meantime?
If you submitted the claim to the Medicare carrier, and haven’t received a response to your initial claim submission, do not automatically submit another claim. Rather, you should:
- Review the automated resubmission cycle on your claim system.
- Wait 30 calendar days from receipt of the Medicare Remittance advice.
- To avoid submitting a duplicate claim, check the status of the initial claim before resubmitting.
If you use a billing service or clearinghouse to submit claims on your behalf, please be sure they are aware of this information. For more information about submitting claims or checking the status of a claim, visit the Claims and Eligibility section.
Have you received a call about updating your information? (05/14/2014)
Blue Cross and Blue Shield of Montana (BCBSMT) is working with a company called Thoroughbred Research Group to help ensure our Provider Finder® has the most accurate and current information about BCBSMT providers. You may receive a call from Thoroughbred Research Group in May and/or June of 2014, with operators asking to verify information published in our provider directory.
If you receive a call from Thoroughbred Research Group on behalf of BCBSMT, please help us by confirming whether or not your information is current. We appreciate your help in making our Provider Finder as accurate as possible for members and providers.
BCBSMT makes no endorsement, representations or warranties regarding any products or services offered by Thoroughbred Research, a third party vendor. The vendor is solely responsible for the products or services offered by them. If you have any questions regarding the services offered here, you should contact the vendor directly.
Providers Can Submit Paper Claims Using Both Versions of the CMS-1500 Paper Claim Form (04/25/2014)
In previous issues of the Capsule News, Blue Cross and Blue Shield of Montana (BCBSMT) reminded providers of the implementation of the revised CMS -1500 form (version 02/12). This revised form replaces the CMS-1500 form version 08/05.
BCBSMT previously announced that the implementation timeline for accepting the new form (version 02/12) and rejecting the previous version (08/05) would follow the Centers for Medicare & Medicaid (CMS) timeline for Medicare. Medicare will only accept claims on the new version after April 1, 2014. Currently, BCBSMT will continue to accept both versions of the paper CMS-1500: the current paper CMS-1500 form (version 08/05) and the revised CMS-1500 form (version 02/12). An updated timeframe for the discontinuation of the CMS-1500 form (version 08/05) will be announced in an upcoming issue of the Capsule News.
If you are submitting claims electronically, please continue to submit the ANSI 837 v5010. If you are not yet submitting claims electronically, now is a great time to sign up. Electronic claim submission can help streamline your administrative process, help protect your patients’ information and may result in faster claim processing and payment. Visit the Provider Education section of our website to learn more.
Tips for using a 270 eligibility/benefit request (04/08/2014)
As of Jan. 1, 2014, providers can view benefit summary information for BCBSMT members who have either converted to or are new to our new processing system. However, the benefit summary for these members is not as detailed as providers may be accustomed to seeing.
To request more information about a member’s benefits, providers can submit a 270 eligibility/benefit request. A link to the request is provided on the Plan Summary page.
Here are some tips to make the 270 request process quicker and easier for providers:
1. Providers must enter their National Provider Identifier (NPI) number. BCBSMT’s new processing system uses the NPI number to determine how detailed the benefit information needs to be when it generates a response to the request.
2. Providers have the option to select a specific Service Type. The drop-down menu includes a large list of options including Chiropractic, Physical Therapy, Hospice, Maternity, Well Baby Care, etc. Depending on the Service Type selected, the provider will get different results that are tied to the type of service.
3. Providers must select a Place of Service. Once the service type is selected, providers can choose from a variety of options under Place of Service including Inpatient, Outpatient, Office, etc. The new processing system uses the Place of Service information to determine the details in the response it generates. If providers do not indicate the proper Place of Service, they may not get all the details they expect to see.
BCBSMT is in the process of fine-tuning conversion processes and hopes to provide easier access to detailed benefit summaries in the near future. In the meantime, submission of a 270 request is the best way for providers to view detailed benefit information for converted BCBSMT members.
NEW! ICD-10 Update: Law postpones ICD-10 implementation
Earlier this week President Obama signed into law H.R. 4302, the “Protecting Access to Medicare Act.” The law amends the Social Security Act to extend Medicare payments to physicians and other provisions of the Medicare and Medicaid programs. Included in the law is a provision that delays the implementation of ICD-9 to ICD-10 until at least Oct. 1, 2015.
BCBSMT had planned to begin ICD-10 testing with providers starting this month. As a result of this delay, BCBSMT will pause provider testing and other implementation activities until a new compliance date is announced. We have made significant progress over the last several years in readying our systems. BCBSMT is well positioned to complete the remaining scope of work once a new implementation date is announced, including end-to-end provider testing.
Please check our provider newsletter, Capsule News for updates on ICD-10.
BCBSMT working with providers on contracts and credentialing
As we look to the immediate future, the implementation of the Affordable Care Act, and the introduction of the Health Insurance Marketplace (Marketplace), Blue Cross and Blue Shield of Montana (BCBSMT) is committed to partnering with health care providers, employers, and the citizens of Montana to bring innovation to health care in Montana. The Marketplace will provide an additional channel for individuals to shop, compare, and purchase health insurance, and, based upon their income, individuals purchasing health insurance on the Marketplace may qualify for a subsidy to assist in paying for their health insurance.
To be designated as a Qualified Health Plan able to sell products on the Marketplace, BCBSMT is required to secure accreditation from a nationally recognized accrediting organization. As a result of this requirement, BCBSMT is transforming its business processes, business structure, and focus on quality improvement to meet standards set by the Utilization Review Accreditation Commission (URAC). As part of this process, BCBSMT is working with health care providers to ensure that they are credentialed and contracted according to URAC standards.
Providers will receive a packet that includes two copies of the newly revised BCBSMT Participating Provider Agreement (“Agreement”). Execution of the Agreement is required for continued participation in BCBSMT’s Traditional Network, PPO, the Federal Employee Program, the BlueCard Program, and the BlueExchange PPO Network. The Managed Care Addendum must be signed in order to continue participation in, or to join, the BCBSMT Managed Care Network. The Healthy Montana Kids (HMK) and Medicare Advantage provider contracts are not affected by this new Agreement.
For administrative simplification purposes, the contracts are now the same for individual and group providers. In the future, new providers may be added to the contract by completing the Addition of Individual Provider form, which is attached to the contract as Exhibit B. Although a new contract will not be required when a provider joins the practice, a separate credentialing application will be required for each new provider who is not already credentialed with BCBSMT.
If you are not already credentialed by BCBSMT, complete the credentialing application and provide copies of documents required.
The credentialing process takes an average of 45 days to complete. Therefore, timely submittal of complete information is very important to avoid delay in your participation status. The information submitted in the application will be verified and reviewed by a Credentialing Committee, which consists of health care providers. You will receive notice of the outcome of your credentialing process once the Committee has made its determination.
If contracts are submitted for a start date prior to your credentialing date, your participating provider status effective date will be the date you are approved by the Credentialing Committee, which will notify you of your credentialing status. Under separate cover, you will receive notice of your BCBSMT provider identification number, your participating provider effective date, and signed copies of your contracts.
If you are practicing prior to your participating provider effective date, you will be established as a nonparticipating provider with compensation being sent directly to the member until such time your participation provider status is effective.
When you receive the packet, please review and sign page 18 of the Agreement for participation in the BCBSMT Traditional Network, PPO, the Federal Employee Program, the BlueCard Program, and the BlueExchange PPO Networks, and page 2 of the Managed Care Addendum if you currently participate in the managed care network or wish to join the managed care network. Sign both copies of the Agreement and Addendum, if applicable, and retain one copy for your records and return the other copies to BCBSMT in the self-addressed stamped envelope provided, or by e-mail to HCS X6100@bcbsmt.com or fax to 1-406-437-7879.
The Agreement must be returned prior to April 1, 2014.
Important: Please note that the compensation amounts for covered services are not changing at this time.
Thank you for your attention to this very important matter.
For questions regarding the contract or credentialing, please contact your Network Representative at 1 800 447 7828 at the following extensions, or email them at the email address indicated:
ALERT! Number for calls for expedited appeals or peer-to-peer reviews
An issue has been identified in the routing of calls for providers requesting expedited appeals or peer-to-peer reviews. Until further notice, please call 800.447.7828, and request extension 6454 to speak directly with the Montana Health Care Management department.
Are you submitting professional paper claims? You may need to take action!
As a reminder, payers began accepting the revised version of the CMS-1500 paper claim form (version 02/12) as of Jan. 6, 2014. According to the transition timeline announced by the National Uniform Claim Committee (NUCC), payers will accept claims submitted on either the revised form (02/12) or the previous version (08/05) through March 31, 2014. After this date, the dual-use period will end and payers will receive and process only those claims that are submitted on the revised CMS-1500 claim form (version 02/12).
As part of the transition, you may need to:
- Order new paper claim forms – Refer to the NUCC website at nucc.org for details.
- Talk with your vendor(s) – Is your software vendor, billing service or clearinghouse prepared to accommodate changes?
- Consider switching to electronic claim submission – Visit the Provider Education/Claims section of our website at bcbsmt.com/provider to learn more.
Effective date for provider fee schedule postponed
For 2014, Blue Cross and Blue Shield of Montana has made the business decision to postpone the effective date of its provider fee schedule update to Sept. 1, 2014. Typically, provider fee schedule updates become effective May 1.
Two factors contributed to the postponement for 2014: 1) Federal government shutdown in 2013 delayed the release by CMS, of the Relative Value Unit information used to determine the rate; and 2) Blue Cross and Blue Shield of Montana continues to transition its business processes to the claims and membership platform of the Health Care Service Corporation (HCSC). Currently, Sept. 1, 2014, is the scheduled date that all claims and membership will have transitioned to HCSC systems.
New CPT codes that became effective Jan. 1, 2014, have been added to the existing provider fee schedule, using the processes identified in our compensation policies.
Enhancements in Claims Processing Efficiency
In the second quarter 2014, Blue Cross and Blue Shield of Montana (BCBSMT) will begin accepting partial batches, rejecting only individual claims that do not meet HIPAA compliance standards.
When you transmit ANSI 5010 837 professional or institutional claim file(s), BCBSMT will forward all valid and successful claims for processing and adjudication. Our payer response reports will indicate which claims were rejected so that those claims may be corrected and resubmitted as appropriate. The entire batch of claims should not be resubmitted, as this will result in duplicate claims within the adjudication process.
If you use a billing service or clearinghouse to submit claims on your behalf, please be sure they are aware of this information.
If you have any questions about this notice, please contact our Electronic Commerce Center at 800-746-4614 for further assistance.
Member ID card alert
Every BCBSMT member ID card should have an alpha prefix with a 9-digit number. However, for some members, new ID cards were incorrectly generated with an extra digit. If you find a 10 digit number, please drop the first zero (0) following the alpha prefix when submitting claims or checking eligibility. Corrected ID cards were mailed to these members on January 9, 2014.
EFT, ERA and EPS Delays (12/26/2013)
Blue Cross Blue Shield of Montana is currently experiencing delays of all Electronic Funds Transfer (EFT), Electronic Remittance Advice (ERA) and Electronic Payment Summary (EPS) files for the production date of Dec. 23, 2013, that would have been delivered on Dec. 24, 2013.
No files were scheduled to be processed over the recent holiday. The next processing date for EFT, ERA and EPS files to be generated is Dec. 27, 2013. View the 2013 Holiday Schedule Reminders for additional information.
We are working to resolve this issue as quickly as possible and will provide an update once the delayed EFT, ERA and EPS files are available.
Claim Number Format Change on Electronic Payer Responses
Blue Cross and Blue Shield of Montana assigns a Document Control Number to each claim we receive. This DCN allows us to monitor claim volumes while tracking the progress of each individual claim throughout the process.
For electronic claims, you or your billing service or clearinghouse can find the DCN on the electronic payer response report. Currently, the DCN on your payer response contains a combination of 12 alpha and numeric characters, such as 123456A7891X.
Effective Oct. 13, 2013, the DCN was enhanced so that the second to last character in the sequence will always be zero as in the following example: 123456A78910X. When you are conducting research on a particular claim, be sure to reference the enhanced DCN for faster, more accurate results.
If you have any questions regarding this notice, please contact our Electronic Commerce Center at 800-746-4614.
Enhanced Voucher Numbering Process
Blue Cross Blue Shield of Montana is enhancing the numbering system for vouchers used for payments to providers. The current process generates zeros as place holders in the voucher number field when no payment is being issued to a provider. The system will now create a new eight character voucher number beginning with the letter “N” and subsequent unique seven digit number. The generation of a valid voucher number eliminates the problems caused when all zeros were used to indicate no payment on the Electronic Payment Summary (EPS) and paper Provider Claim Summary (PCS).
Additionally, the format for voucher numbers provided in the Electronic Remittance Advice (ERA) data is changing to include a new date prefix and suffix built around the voucher number. In the following example, C13nnnN12345670, the new format reads:
- C (claims)
- 13 (year)
- nnn (Julian calendar date)
- N1234567 (voucher number)
- 0 (sequence number)
This new format will help improve the accuracy and efficiency of these electronic and paper transactions.
Electronic Funds Transfer Delays (October 17, 2013)
Blue Cross and Blue Shield of Montana (BCBSMT) completed a system upgrade last weekend for Electronic Funds Transfer (EFT) transactions. Our bank experienced a delay in upgrading and processing our files due to the banking holiday on Monday, October 14, 2013.
Technical difficulties this week at BCBSMT have caused further delays and, as a result, our files for October 14, 2013, could not be sent until October 17, 2013. This means funds that would have been dispersed via EFT to providers as of October 17, 2013, could not be made available until Friday, October 18, 2013.
We appreciate your patience and apologize for any inconvenience caused by the issue.
New Claim Reject
Blue Cross and Blue Shield of Montana (BCBSMT) often sees claims billed with incorrect member data. When this occurs, BCBSMT uses an internal process to select a member and process the claim. Effective September 1, 2013, BCBSMT will systematically reject any claim that does not specify a member after the internal process is applied. When a claim is rejected, providers will receive a letter that states BCBSMT is unable to select a member using the Health Plan ID and patient information provided.
Please verify the information provided on the Health Plan ID card you received from the member. If the information on the Health Plan ID card does not match the information on the claim, submit a new claim with the corrected information. If the information on the Health Plan ID card does match the information on the claim you submitted, notify the patient and have him or her contact us directly to assist in this process.
Should you have any questions about this communication, please contact your Provider Account Consultants by email at email@example.com or 1 800 447-7828, Extension 6100, option 3.
Updating Code Editing Software to ClaimsXten for FEP and HOST Claims (updated 10/31/2013)
Blue Cross and Blue Shield of Montana (BCBSMT) will begin using McKesson ClaimsXtenTM code auditing software to process Individual and Group business claims on January 1, 2014.
For business that has not transitioned to HCSC systems, claims will continue to process on the BCBSMT claims system with the iCES code auditing software.
This software will continue to allow efficient, consistent claims processing to evaluate the accuracy and adherence of reported services to accepted national reporting standards. Please refer to the BCBSMT Compensation Policies for related information about reimbursement guidelines.
BCBSMT looks forward to providing you access to Clear Claim ConnectionTM (C3) in early 2014. This provider resource will allow disclosure of claim auditing rules and clinical rationale to the BCBSMT independently contracted provider network.
For additional information about the ClaimsXten implementation, view answers to ClaimsXten Frequently Asked Questions at: ClaimsXten Frequently Asked Questions.
ClaimsXten, ClaimCheck and Clear Claim Connection are trademarks of McKesson Information Solutions, Inc.
McKesson Information Solutions, Inc., is an independent third party vendors and are solely responsible for their products and services. BCBSMT makes no representations or warranties regarding the products or services provided by any of these vendors. If you have any questions regarding the products or services provided by these vendors, you should contact the vendor directly.
Important Notice regarding new claims processing system
Claims must be submitted with your appropriate NPIs. Our new claims processing system requires a billing NPI. If you are a group, you must bill a rendering NPI and a billing NPI in the appropriate fields. If you are a group and have more than one billing NPI, we must have each of those numbers on file; if the number is not on file, claims will be rejected.
If you are a solo practice and submit a rendering NPI and a billing NPI, and we do not have your billing NPI on file, your claim will be rejected. We are reviewing reports of rejected claims. If we find you are sending a billing NPI, it will be added to your file. We will notify you when you can resubmit your claims.
BCBSMT aligns with HCSC effective August 1, 2013
Following the necessary regulatory approvals last month for the proposed alliance between Blue Cross and Blue Shield of Montana (BCBSMT) and Health Care Service Corporation (HCSC), we are pleased to announce that we have officially completed the transaction, effective August 1, 2013.
In doing so, BCBSMT has joined the Blue Cross and Blue Shield Plans in Illinois, Texas, New Mexico, and Oklahoma as one of the five Blue Cross and Blue Shield operating divisions of HCSC -- a mutual legal reserve company that has operated as a not-for-profit for 75 years. As is the case in these other states, BCBSMT will keep its name and will continue manage relationships with hospitals and physicians at the local level. Information for providers has been made available through routine updates on the BCBSMT provider portal and through “The Capsule News.” Please refer to those resources as they are being constantly updated with information that may be pertinent for providers relative to the alliance.
This alliance is important for Montana because it provides access to needed technology and innovation, cutting-edge customer service systems, economies of scale, and additional jobs in the state.
This alliance is also important because through it, BCBSMT will continue the legacy of caring for Montanans through collaboration with Montana’s hospitals and physicians. This legacy was forged through Montana’s Blue Cross Plan, founded by hospitals in 1940, and Montana’s Blue Shield Plan, founded by physicians in 1946.
We look forward to this exciting new chapter in BCBSMT’s history and continuing to collaborate with hospitals and physicians for years to come.
Should you have any questions or comments, please do not hesitate to contact Paul Pedersen Paul_Pedersen@bcbsmt.com or at 406.437.6065 and/or Mark Burzynski Mark_Burzynski@bcbsmt.com or 406.437.6006.
Provider Online Inquiry for BlueCard Host and FEP
Claim Status - To submit a request for claim status, access the BlueCard Host and FEP Claim Search area located on the bottom portion of the screen that appears after you log into the BCBSMT.COM website. The Health Plan ID/Sub ID and Date Submitted are required and will expedite your request.
- FEP Members – If the claim submit date is equal to or after the date our FEP line of business converted, you will be directed to the BlueExchange/FEP New Claim Request screen. If the claim submit date is prior to the conversion date, we will display the claim data similar to how it appears today.
- BlueCard Host Members – Enter the Health Plan ID/Sub ID and the claim submit date. All claims on file submitted by your office will display. If the claim you are searching for does not display, click on the New Claim Request button located above the claim results. You will then be able to submit your request using the BlueExchange/FEP New Claim screen.
ELIGIBILITY/BENEFIT STATUS – Continue to submit your eligibility and benefit requests using the BlueExchange/FEP menu option on the left side of the screen.
For both claim status and eligibility/benefit requests through BlueExchange/FEP section of our site, you will be required to enter the Provider NPI associated with your office and the claim that was submitted on behalf of the member. If you registered for online access with your NPI Number, it will be automatically entered for you. You may have to enter the NPI Number if you registered using your Montana Provider Number.
Conversion Factors Increase May 1, 2013
Effective May 1, 2013, BCBSMT is increasing the resourced-based relative value system (RBRVS) conversion factor to $55.35 and the anesthesia conversion factors to $59.00.
In the RBRVS system, services are assigned units of value, known as Relative Value Units (RVU), based on the resources (physician’s work, the practice expense, and professional liability insurance) required to provide the services. BCBSMT uses the Transitioned Non-Facility RVU and Transitioned Facility RVU totals. The applicable total RVU is multiplied by the BCBSMT conversion factor to calculate the BCBSMT allowable fee for participating providers.
Payment for the administration of anesthesia is based on the American Society of Anesthesiology methodology. The compensation method for physicians and certified registered nurse anesthetists is a base and time unit calculation (base units plus time units multiplied by the conversion factor). Anesthesia time is reported in minutes, and each 15-minute increment equals one unit. Log in to Provider Online Services for additional information on Relative Value Unit and Anesthesia Compensation policies.
TriWest Creates Transition Claims Processing Matrix
On April 1, 2013, the managed care support contract for the TRICARE West Region will transition to UnitedHealthcare Military & Veterans (UnitedHealthcare). TriWest Healthcare Alliance (TriWest) will remain the TRICARE West Region managed care support contractor through March 31, 2013.
TriWest has created a Transition Claims Processing Matrix to help providers determine how to submit claims based on dates of service, admit and discharge dates, and the date the claim or adjustment was received.
If you have identified any TRICARE West Region claims issues, please submit them as soon as possible. Registered users of TriWest.com may submit claims issues online using online claims correspondence/Webmail.
Visit the Transition Update Center at TriWest.com/Provider to find important information regarding the TRICARE West Region transition on the following topics:
This information on these pages is considered valid as of the publication date and may change as the transition to UnitedHealthcare progresses. Please refer to TriWest.com/Provider frequently for updates.
For questions or concerns about any Announcements, please contact your Health Care Services Provider Account Consultants at 1.800.447.7828.