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BlueCard Articles

Published August 22, 2013

Published August 7, 2013

Updating Code Editing Software to ClaimsXten for FEP and HOST Claims

Blue Cross and Blue Shield of Montana (BCBSMT) has used the code editing software ClaimCheck®, developed by McKesson Information Solutions, Inc., for review of FEP claims since April of 2000. The BCBSMT customized version of this software is called CAI (Claims Accuracy Initiative). When claims processing transitions to Health Care Service Corporation (HCSC), the code editing software will be updated to McKesson’s, ClaimsXtenTM. HOST claims processing transitioned to HCSC systems will also process with ClaimsXten.

This software will continue to allow efficient, consistent processing of claims to evaluate the accuracy and adherence of reported services to accepted national reporting standards. Please refer to the BCBSMT Compensation Policies where you will find information about reimbursement guidelines that vary for FEP business.

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.  

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. 
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BlueCard Host Business will be Transitioned to Health Care Service Corporation in July 2013

 

 

BlueCard Host claims will begin processing through the Health Care Service Corporation (HCSC) starting July 22, 2013. 

  • The submission process of claims by Montana providers will remain the same.  Please continue to use PO Box 7982, Helena, MT 59604 for paper submission.
  • Provider Claims Registers (PCRs) for claims submitted on or after July 22, 2013, will look different because they will be coming from a new claims system.
  • BCBSMT BlueCard Host staff members will work with HCSC staff members to continue processing adjustments related to claims that previously processed in our Montana claim system.  PCRs for these adjustments will continue to arrive through our current processes.

On August 12, 2013, BlueCard Host provider telephone and written inquiries will begin processing through the Health Care Service Corporation (HCSC).

  • Continue to dial 1.800.447.7828 for inquiries related to BlueCard Host claims.  You will be routed to the appropriate area through the IVR system.
    • Hours of availability are:
           Monday through Friday 5:00 a.m. – 10:30 p.m. (Mountain Time)
           Saturday 5:00 a.m. – 2:30 p.m. (Mountain Time). 
  • Please continue to use PO Box 4309, Helena MT 59604 for submission of paper correspondence.  Again, the information will be routed to the appropriate area.
  • You will notice a change in your IVR experience beginning August 1, 2013, because calls will be routed through HCSC’s IVR system.
  • Please dispose of any direct phone numbers that you might have on file for BlueCard Host team members, as they will no longer be able to help you with claims.
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New Self-Service Options Available!

On July 22, 2013, Interactive Voice Response system (IVR) options will be available for BlueCard Host inquiries. The IVR uses voice recognition technology, so all you have do is speak your request – the IVR does the rest! 

Hours of availability are:
          Monday through Friday 5:00 a.m. – 10:30 p.m. (Mountain Time)
          Saturday 5:00 a.m. – 2:30 p.m. (Mountain Time). 

Simply dial 1.800.634.3569 for eligibility, benefits and claims status can. A fax back option confirming the information provided is available. 

Have Ready;

  • National Provider Identifier (NPI)
  • Patient’s health plan ID
  • Date of birth
  • Date of service

Additional Tips

  • Avoid using cell or speaker phones
  • Feel free to interrupt
  • Speak clearly
  • Speak numbers in a single digit format
    • 72, say seven two vs. seventy-two
  • Minimize background noise, mute phone when not speaking
  • Keypad options are available
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Example Provider Claim Summary (PCS) and Check

Blue Cross and Blue Shield of Montana (BCBSMT) began processing FEP and BlueCard Host claims on Health Care Service Corporation’s (HCSC) claims processing system July 15, 2013. If you currently receive a Provider Claim Remittance (PCR) and check from BCBSMT, you will notice a change in these documents. Once the transition to the new system is complete, your Provider Claim Summary (PCS) and check will be similar to the examples shown below.

Cutover dates: 
Payments for BlueCard Host claims submitted on or after July 22, 2013, will be reimbursed by the HCSC claims system. 

In addition to the format of the documents being different, these changes should be noted. 

  • PCSs do not reflect refund messages. You will be notified of overpayments in a separate letter. 
  • The PCS will not show reversals, only positive payments.
  • When a recoupment occurs, a detail page will be printed to accompany the PCS as explanation.
  • Recoupments will only be offset on checks that are $50 or more.
  • Claim messages and adjustment reasons will be indicated by a number. A message key is included in the PCS detailing the claim messages.

Note: If you are enrolled to receive electronic claim summaries (ECS), they will provide the same information as described above.

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BlueCard Host Claim Submission After the Transition

Beginning July 22, 2013 for BlueCard Host, electronic and paper claims will be processed through the claim systems of the Health Care Services Corporation (HCSC).

  • Continue submitting claims in the same manner that you do today.  Utilizing PO Box 7982, Helena, MT 59604 or your electronic claim submission vendor.
  • Claims will be reviewed in HCSC’s verification system for completeness and will be returned for additional information if necessary.
  • HCSC enjoys a 91% first pass rate on their claims.  This means that 91% of their claims are not stopped in their system for manual review and demonstrates a positive outcome for timely claims processing.
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BlueCard Host Electronic Remittance Advice (ERA) and Electronic Funds Transfer (EFT)

Providers, who currently receive ERAs and/or EFTs, will be automatically enrolled so no action is required. The ERA and EFT enrollment will be completed for you.

ERA
Effective 7/15/2013, providers who currently receive ERAs and/or EFTs from Blue Cross and Blue Shield of Montana’s (BCBSMT) QNXT system, will also begin receiving ERAs from the new processing system. No action is needed from you.

EFT
You will receive two EFTs - One from the new processing system for those groups that have been moved to Health Care Service Corporation (HCSC) and one from BCBSMT’s QNXT system.  No action is needed from you.

Paper Remit
You will receive a paper remit for the first 30 days from the new processing system and then the paper will be turned off.

Electronic Payment Summary (EPS)
New! This is an electronic version of your paper remit and arrives faster than the paper remit. Providers who receive ERAs will be enrolled automatically for EPS.

Host Claim Adjustments
Any claim adjustments will process on BCBSMT's QNXT system. 

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Provider Online Inquiry for BlueCard Host

Claim Status - To submit a request for claim status, access the BlueCard Host Claim Search area located on the bottom portion of the screen that appears after you log into bcbsmt.com.  The Health Plan ID/Sub ID and Date Submitted are required and will expedite your request.  If the Claims Submit Date is equal to or after the date that 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 date that line of business converted, the claim data will display similar to the way it appears today.

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 the 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.

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New process for BlueCard Host Refunds and Overpayments

BlueCard Host overpayments that are identified on or after July 22, 2013 will follow the new process that is outlined below.

Overpayments identified by Blue Cross and Blue Shield of Montana – providers will receive a letter to explain the overpayment.  You will be afforded the opportunity to return the overpaid funds via check or by requesting that we withhold from future payments.  If no response is received within 30 days, the overpayment will be subject to auto-recoupment by withholding from future payments.

Overpayments identified by a provider by phone call or paper correspondence – providers will receive a letter to explain the overpayment.  You will be afforded the opportunity to return the overpaid funds via check or by requesting that we withhold from future payments.  If no response is received within 30 days, the overpayment will be subject to auto-recoupment by withholding from future payments.

Overpayments identified by a provider accompanied by a check – potential overpayments will be reviewed and claim adjustments will be performed per the provider’s request.

***overpayments for BlueCard Host claims processed prior to July 22, 2013 will continue to process as they currently are at this time.

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Durable Medical Equipment RR and NU Modifiers

On July 15, 2013, claims began processing on Health Care Service Corporation’s (HCSC) claims processing system. Claims billed for Durable Medical Equipment (DME) charges will pay according to what is submitted on the claim with no manual review.  When claims are billed with a rental modifier (RR) and/or a purchase modifier (NU), they will process according to the modifier indications. However, if a DME charge is submitted with either modifier, it will process according to the rental (RR) fee schedule.

Please be aware of this change when submitting claims after this date.

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Professional, Technical and Global Modifier Pricing for Professional Claims

Professional claims (HCFA 1500 forms) for CPT (HCPCS) codes with a professional (26) and/or technical (TC) modifier are processed using HCSC’s claims processing system effective July 15, 2013.

When a service is submitted with a TC modifier appended and the place of service is Inpatient (POS 21), Outpatient (POS 22) or Emergency Room (POS 23), Blue Cross and Blue Shield of Montana (BCBSMT) will establish the allowance for the service using the 26 modifier fee schedule.  It is not appropriate for a professional provider to bill for the technical component in a facility setting. The modifier will not be changed on the claim, but the allowed amount will reflect the allowed amount for the 26 modifier.

When a service is submitted with no modifier appended and the place of service is Inpatient (POS 21), Outpatient (POS 22) or Emergency Room (POS 23), BCBSMT will establish the allowance for the service using the fee schedule for the 26 modifier. It is not appropriate for a professional provider to bill for the global service in a facility setting. The 26 modifier will not be added to the service line, but the allowed amount will reflect the allowed amount for the 26 modifier.

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Place of Service Processing Changes

On July 15, 2013, Blue Cross and Blue Shield of Montana (BCBSMT) began processing claims on Health Care Service Corporation’s (HCSC’s) claims processing system. We implemented the following changes for the application of the Facility and Non-Facility Relative Value Unit (RVU) for the Place of Service values listed below.

The following place of service code values are changing from Non-Facility to Facility:
POS 57 = Non-residential Substance Abuse Treatment Facility
POS 62 = Comprehensive Outpatient Rehabilitation Facility

The following place of service code values are changing from Facility to Non-Facility:
POS 26 = Military Treatment Facility
POS 34 = Hospice
POS 53 = Community Mental Health Center

These changes will affect compensation if the RVU is different for the Facility and Non-Facility as published on the Centers for Medicare and Medicaid Services (CMS) Resource Based Relative Value System (RBRVS).

Please refer to the Compensation Policy entitled, 'Place of Service Compensation Policy.'

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Secondary Bilateral Procedure Reporting

Modifier 50 is reported when one procedure code is performed bilaterally (e.g. CPT 19305, mastectomy performed on the left and right side).  A bilateral primary procedure may be reported on one line with Modifier 50.  Bilateral primary procedure compensation is 150 percent of the allowable fee for one service.

A bilateral secondary procedure, when reported on two separate lines with the same procedure code and modifier 51, is compensated at 50 percent of the allowable fee for one procedure for each line, each being compensated as a secondary procedure.

Example:

  • Line 1 – CPT Code 29888 is performed bilaterally and is the primary procedure—modifier 50 is appended to procedure code 29888 and the allowed amount is 150 percent of the fee schedule.
  • Line 2 – CPT Code 29881 is performed on the LT and is the secondary procedure—modifier 51 is appended to procedure code 29881 and the allowed amount is 50 percent of the fee schedule.
  • Line 3 – CPT Code 29881 is performed on the RT and is the secondary procedure—modifier 51 is appended to procedure code 29881 and the allowed amount is 50 percent of the fee schedule.

On July 15, when claims began processing on Health Care Service Corporation’s (HCSC’s) claims system, bilateral secondary procedures reported on one line with a 50/51 modifier combination are compensated at 75 percent of the allowable fee for one service
Example:

  • Line 1 – CPT Code 29888 is performed bilaterally and is the primary procedure — modifier 50 is appended to procedure code 29888 and the allowed amount is 150 percent of the fee schedule.
  • Line 2 – CPT Code 29881 is performed bilaterally and is the secondary procedure— modifier combination 50/51 is appended to procedure code 29881 and the allowed amount is 75 percent of the fee schedule.

Please refer to the Compensation Policy entitled, 'Modifier Use When Coding Claims Policy.'

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Assistant Surgery Services Billed by Midlevel Providers

Beginning July 15, 2013, a change will occur for claims processed on the Health Care Service Corporation (HCSC) claims processing system for assistant surgery services billed by a midlevel provider (including Nurse Practitioner, Physician Assistant, and Clinical Nurse Specialist).  

Modifiers 80, 81 and 82 are appropriately reported for assistant surgery services performed by an MD, DO, or DPM only.   Modifier AS is appropriately reported for assistant surgery services performed by a midlevel provider. 

If a midlevel provider bills an 80, 81 or 82, the allowed amount for this service will be based on the AS modifier allowed amounts. The AS modifier allowed amount is 10% of the physician’s allowable fee for the primary procedure, and 5% of the physicians’ allowable fee for each secondary procedure.

Modifier 80:  Assistant Surgeon (Bill only for MD, DO, DPM providers).

Modifier 81:  Minimum Assistant Surgeon- Appended when an assistant surgeon is used for a relatively short period of time (Bill only for MD, DO, DPM providers).

Modifier 82:  Assistant Surgeon (when qualified resident surgeon not available):  (Bill only for MD, DO, DPM providers).

Modifier AS:  Physician Assistant, nurse practitioner, clinical nurse specialist, RN First Assist services for assistant at surgery. 

Please refer to the Modifier Use When Coding Claims Policy on the BCBSMT website.

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Outpatient Diagnostic Laboratory, X-Ray, and Machine Test Services (DXL), and Outpatient Physical Therapy, Occupational Therapy, and Speech Therapy Services (PT/OT/ST) Provider Claims Register (PCR) Changes

Blue Cross and Blue Shield of Montana (BCBSMT) is changing the way that PCR’s will be displayed for services billed under the Outpatient DXL and PT/OT/ST agreements. Currently these services have their own separate PCRs because they are processed under unique provider identification numbers. 

For claims processed on the Health Care Service Corporation (HCSC) claims system beginning July 22, 2013, these services will be processed under the hospital’s provider identification number.  These claims will be reported on the hospital’s PCR.

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