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Federal Employee Program 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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New Self-Service Options Available!

On July 15, 2013, Interactive Voice Response system (IVR) options will be available for the Federal Employee Health Benefit Plan (FEHBP) 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; including pre-auths. A fax back option confirming the information provided is available.    For pre-certifications dial 1.877.855.3751.

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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FEP EIVR Script and Guide

Welcome to the BCBS Federal Employee Program 

Montana 1.800.634.3569      pre-certification: 1.877.885.3751

Providers must complete one transaction before it will allow them to ask for a CA.

Are you calling as a member or a health care professional?

  • Say Health Care Professional

To direct your call please say:

  • Prescription Drugs
  • Medical
  • Dental
  • Behavioral Health

In order to get eligibility and benefits, we need your rendering NPI.
For claims and other inquiries, we need your billing NPI. Now, what is your 10-digit NPI?

Which can I help you with?

  • Say Eligibility and Benefit or press 1

  • Say Claims or press 2
  • Say Preauthorization or press 3
  • Say Other Services or press 4

Eligibility

What is the Subscriber’s ID?

  • The provider needs to speak the subscriber’s ID to include the R in front of it (R00000000)
    ***A valid subscriber ID is required to receive patient-specific information***

What is the patient’s date of birth?
***The month, date and year are required ~07-21-1967 or July 21st, nineteen sixty-seven***

The system will confirm the patient is covered with the following:

  • Type of coverage
  • Current effective date
  • Alpha prefix
  • Group number
  • Confirmation number

Now you can say …

  • Repeat that or press 1
  • Benefit Details or press 2
  • Next Patient or press 3
  • Main Menu or press 4

Benefit Details

Are you calling from a physician’s office or facility?

  • Say physician’s office or facility

Tell me a service:

  • Say, for example, Office Visit, Chiropractic Services or say List Them

The EIVR currently offers the benefits below:  
There are only 16 benefit categories available for FEP.  Here's a list of the categories and sub-categories available.  The caller will have to opt out to a Customer Advocate for any benefit NOT listed below:

  • Accidental Injury
  • Allergy
  • Catastrophic Protection
  • Chiropractic Services
  • Dental
  • Diagnostic/Lab and X-Ray
  • Drugs
    • Retail Pharmacy
    • Mail Order Program
  • Durable Medical Equipment
  • Hospice or Home Nursing Care
    • Home Nursing
    • Home Hospice
    • Inpatient Hospice
  • Inpatient Benefits
    • Facility Benefits
    • Professional Benefits
  • Maternity
    • Professional Benefits
    • Facility Benefits
  • Mental Conditions or Substance Abuse
    • Inpatient Benefits
  • Professional Benefits
  • Facility Benefits
    • Outpatient Benefits
      • Office Visits
      • Outpatient Benefits
      • Day Surgery Benefits
      • General Outpatient Benefits
  • Physical, Occupational, or Speech Therapy
    • Preventive Care
    • Physical Exams
    • Cancer Screenings
    • Adult Routine Immunizations
    • Well Child Care

Unless otherwise noted above, all benefit categories will voice back Professional and Facility benefits within the same script.  Preferred, Participating, and Non-Participating benefits are also voiced within the same script.  View PDF of script.

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Federal Employee Health Benefit Plan Business Will Be Transitioned To Health Care Service Corporation In July 2013

 

 

On July 8, 2013, the Federal Employee Program (FEP) Director’s Office will begin reissuing all ID cards for Blue Cross and Blue Shield of Montana Federal Employee Health Benefit Plan (FEHBP) members.

You may request copies of the Service Benefit Plan Member ID cards on or after July 15, 2013, to ensure you have the most current information for your files.

While the Health Plan ID, known as the “R” number, will remain the same, the contact information for precertification will change effective July 15, 2013.  All other information on the ID card will remain the same.

  • The dedicated toll free Customer Service number for the FEHBP will remain the same.  Please continue to dial 1.800.634.3569.
    • To ensure you reach the right destination, please do not dial numbers
            437.5000 or 1.800.447.7828. 
      If these numbers are dialed, you will be prompted to hang up and dial direct the dedicated toll free number.
  • The toll free number for precertification (located on the back of the member ID card) will change to 877.885.3751.
  • Please be sure to replace this new number in your office contact information.
  • Continue to use the claims mailing address when it is necessary to submit a paper claim:
    • PO Box 7982
      Helena, MT  59604
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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 FEP claims submitted on or after July 5, 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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FEP Claim Submission After The Transition

Beginning July 15, 2013 for FEP, 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.
  • FEP – Durable Medical Equipment (DME) claims must be submitted with an MD provider ID for the certification process.
  • FEP – Met Life Dental claims will no longer be forwarded as a courtesy.  Please submit the claims to Met Life directly.
  • 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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FEP LRSP Electronic Remittance Advise (ERA) and Electronic Funds Transfer (EFT)

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

ERA
Providers who are receiving Electronic Remittance Advise (ERA/EFT) from Blue Cross and Blue Shield of Montana’s (BCBSMT) legacy system, will no longer receive 835 from the BCBSMT legacy system, effective July 15, 2013. After that date, you will ONLY receive ERAs from the new processing system. No action is needed from you.

EFT
Providers who currently receive ERA and EFT will start receiving these for payments processed after July 15, 2013. 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.

FEP Claim Adjustments
Any claim adjustments after July 15,2013 will be done on the new system ONLY. 

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Provider Online Inquiry For Federal Employee Health Benefit Plan

Claim Status - To submit a request for claim status, access the Federal Employee Health Benefit Plan (FEHBP) 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/BENEIFT 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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Updating Code Editing Software To ClaimsXten For FEP 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.

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 vendor and is solely responsible for its 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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New Process for FEP Refunds and Overpayments

FEP overpayments that are identified on or after July 5, 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 by accompanied by a check – potential overpayments will be reviewed and claim adjustments will be performed per the provider’s request.

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Change In Logic For Traditional Network Discounts

Blue Cross and Blue Shield of Montana (BCBSMT) has been processing facility claims for FEP members who receive service from participating facilities outside of our Preferred PPO network with allowances up to 100 percent of charge depending on the circumstances.

Beginning July 15, 2013, when claims began processing on Health Care Service Corporation’s (HCSC) system, we process facility claims for these situations using the Traditional Network allowance if the facility is not contracted with the member’s network, but is contracted with the Traditional Network.

Note that FEP members who are covered under Basic Option are not covered for services received outside of the Preferred PPO network with the exception of emergency services.

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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 s 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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