Capsule NewsSM
A Newsletter for Montana Health Care Providers

Third Quarter 2014

New Provider Contracting & Credentialing Process

In the near future BCBSMT will transition its credentialing processes to utilize the Council for Affordable Quality Healthcare (CAQH) Universal Provider Data source (UPD), a nonprofit alliance of health plans and trade associations to electronically collect provider credentialing data. CAQH collaborates on initiatives that simplify healthcare administration for health plans and providers.

Providers may utilize the UPD at no cost.

In addition, BCBSMT will be implementing new in-house technology to handle its contracting and credentialing processes.

Initial Credentialing Process

Effective 9/11/14, when a new professional provider applies for network participation, existing providers adding additional providers to their practice contract must submit the Agreement "Add Sheet"/ Amendment B with the new provider's information. New providers not affiliated with an existing contracted practice must request a BCBSMT Provider Record ID by submitting a form, which will be provided on our website at bcbsmt.com. A new Fax number is being established for submittal of these forms, or they may be submitted via e-mail to HCSSPEC@bcbsmt.com.

After receiving either form, BCBSMT will create a provider record and assign a provider i.d. in its system. BCBSMT will then add the provider to its roster with CAQH and for new providers not affiliated with an existing contracted practice, a contract will be sent and will need to be signed and returned. CAQH will send a registration letter including an assigned ID and instructions on how to register using the UPD. The provider is then able to access the UPD database via the Internet and enter the credentialing application. Only organization(s) the provider authorizes will have access to their data. The provider must authorize BCBSMT to view their credentials.

Providers that are already utilize CAQH and are registered must simply authorize BCBSMT to view their credentials.

As you may recall, BCBSMT became a division of Health Care Service Corporation (HCSC) in August of 2013. BCBSMT is working in collaboration with our HCSC partners in the Texas Plan on the credentialing process. Staff in the Texas office will collect additional information required and will verify the information supplied in the credentialing application.

BCBSMT's local Credentialing Committee, consisting of practicing healthcare providers in the state of Montana, will continue to review and approve the applications.

Once the credentialing process is complete, the credentialing approval letter is sent. The contract will be executed and a welcome letter will be sent along with a copy of the executed agreement and effective date of the contract.

As a reminder, the effective date of the contract is the credentialing approval date. Effective dates are not backdated. Please be sure to start the process prior to the provider's start of practice to avoid non-participating status. Once the provider's credentialing information is entered into CAQH, the provider will receive an automatic reminder to review, update and attest to data accuracy once every four months.

Recredentialing Process

BCBSMT will access the UPD database for a provider's data during their scheduled recredentialing cycle every third year. CAQH will automatically transmit information to BCBSMT if information is complete and current. The provider will only receive a recredentialing notice if his/her information in the UPD is not current.

Effective September 1, 2014, CAQH will begin collecting the data required for the BCBSMT recredentialing for providers whose recredentialing is due in December 2014 and going forward. Providers will begin receiving recredentialing notices 6 months in advance of their recredentialing due date, if the provider has not recently updated the CAQH.

Benefits

Working with CAQH will make the credentialing process more uniform and ease your administrative processes, saving both time and money. It will eliminate the need to complete multiple credentialing applications for multiple health plans. Your information can be kept current at all times. You will only receive recredentialing notices if your information in the UPD is not current. The UPD online credentialing application process supports BCBSMT's administrative simplification and paper reduction efforts.

What Next?

If you are already registered with CAQH through your participation with another health plan, you will need to log in to the UPD database at https://upd.caqh.org  and add BCBSMT as one of the health plans authorized to access your information or select "global authorization." This will allow BCBSMT to obtain your current credentialing information from the UPD database. You may do so at this time.

If you are not already registered with CAQH, 6 months in advance of your recredentialing due date, you will be rostered by BCBSMT and will receive notice that you are due for recredentialing and the letter will include your CAQH assigned ID and instructions on how to register using the UPD. You may then access the UPD database via the Internet and enter your credentialing application. If you do not have Internet access, you may call the CAQH Help Desk at 888-599-1771 and complete the application by telephone. Supporting documentation for the credentialing process may be faxed to a specific toll-free fax number 866-293-0414.

If you have a new provider that will be joining your practice, or are a new provider not affiliated with an existing contracted practice follow the current process until 9/10/14. On and after 9/11/14, follow the Initial Credentialing process defined above to obtain a BCBSMT provider record. Please account for time to complete the entire process prior to the provider's start date. The process takes an average of 45 days to complete.

Resources

Please watch the BCBSMT Provider page at bcbsmt.com for more information in the future. The Provider page will be updated to provide resources to guide providers through the process.

For more information on the CAQH application process visit its web site at http://www.caqh.org . The CAQH Help Desk may be reached by phone at 888-599-1771 or e-mail at caqh.updhelp@acsgs.com.

Recontracting Reminder: Action Required

Earlier this spring, professional providers in the Blue Cross and Blue Shield of Montana (BCBSMT) participating provider network received a new contract to sign. If you have not returned your new contract, please do so immediately. Contracts may be faxed to 800-437-7879 or e-mailed to HCSSPEC@bcbsmt.com.

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 URAC accreditation standards. As part of this process, BCBSMT is working with health care providers to ensure that they are credentialed and contracted according to URAC standards.

To simplify administrative procedures, 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. 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. All provider types are now required to be successfully credentialed prior to participation in the BCBSMT networks.

iEXCHANGE® is here; training available

BCBSMT is proud to introduce iEXCHANGE, our web-based pre-authorization tool that supports direct submissions and provides online approval for:

  • inpatient admissions
  • select outpatient services
  • select pharmacy services
  • select behavioral health services

iEXCHANGE is available to contracting providers with Blue Cross Blue Shield of Montana 24 hours a day, seven days a week - with the exception of every third Sunday of the month when the system is brought down from 10 a.m. to 2 p.m. MT for system updates. iEXCHANGE is available for converted members only; please see the alpha-prefix reference guide PDF Document to determine conversion dates.

Getting started with iEXCHANGE

You will need a User ID, iEXCHANGE ID and password to gain access to the tool.

  • To set up a new account, you must be a contracted physician, professional provider or facility within Montana. If you meet the criteria, visit complete and submit the form available at https://www.bcbsil.com/provider/forms/mt/iexchange_enrollment.html.
  • If you are a new employee in an office that already uses iEXCHANGE, contact your assigned group administrator for a new username and password.
  • The iEXCHANGE portal Provider login  can be added to your favorites.

Training available

For a successful experience with the iEXCHANGE portal, we encourage you to attend a training webinar. Three webinars are currently scheduled as more will be added as needed. To register, click on the date you would like to attend:

For more information, visit the iEXCHANGE page on BCBSMT's website.

Pharmacy Program to Add an Electronic Prior Authorization (PA) Process

BCBSMT is adding a new electronic process for submission of prior authorization (PA) requests for drugs that are part of our PA program and that may be considered for coverage under the member's pharmacy benefit. Prime Therapeutics, our pharmacy benefit manager, is converting the current inventory of paper PA forms to a library of electronic forms that can be easily accessed, completed and submitted online. In addition to reducing paper, the new electronic PA process will help increase security of your patient's protected health information. It is also faster - your office will receive a response in real-time upon receipt and processing of each online PA request. Watch for more details in the Capsule News and Announcements section of our website.

Prime Therapeutics LLC is a pharmacy benefit management company. BCBSMT contracts with Prime to provide pharmacy benefit management, prescription home delivery and specialty pharmacy services. BCBSMT, as well as several other independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime.

Using National Drug Codes (NDCs) on Professional Claims

BCBSMT requests the use of NDCs and all related information when drugs are billed on medical professional/ancillary electronic (ANSI 37P) and paper (CMS-1500) claims.

Currently, NDCs are requested when Not Otherwise Classified (NOC) codes are billed on medical claims, along with the applicable Current Procedural Terminology (CPT®) or Healthcare Common Procedure Coding System (HCPCS) code(s), to better identify certain unlisted drugs for proper adjudication of your claim.

Use of NDCs will play an increasingly prominent role in months to come as enhancements are made to our Pharmacy Program. If you are not familiar with NDCs, please see below for a quick overview that offers basic guidelines on what the NDC is, where to find it and what NDC-related information needs to be included on your claim.

An NDC is a unique, three-segment numeric identifier assigned to each medication listed under Section 510 of the U.S. Federal Food, Drug and Cosmetic Act. When billing with an NDC, a five-digit, four-digit, two-digit format (xxxxx-xxxx-xx) (no spaces no hyphens) is used. The first segment of the NDC identifies the labeler (i.e., the manufacturer). The second segment identifies the product (i.e., the specific strength, dosage and formulation of a drug). The third segment identifies the package size and type.

The NDC is found on the medication's packaging. An asterisk may appear in place of leading zeroes for each segment. If the NDC on the package label is less than 11 digits, a leading zero must be added in the appropriate segment. The container or label also displays information on the unit of measure for the drug. Examples of NDC units of measure are listed below:

  • UN (Unit) — Powder for injection (needs to be reconstituted), pellet, kit, patch, tablet, device
  • ML (Milliliter) — Liquid, solution, or suspension
  • GR (Gram) — Ointments, creams, inhalers or bulk powder in a jar
  • F2 (International Unit) — Products described as IU/vial or micrograms

When billing with NDCs on claims, the applicable CPT or HCPCS code(s) must also be included, along with the number of CPT/HCPCS units. In addition to the NDC, also include the NDC qualifier (N4), NDC unit of measure, and the number of NDC units - including decimals.

Please continue to watch the Capsule News, as well as the Announcements section of our Provider website for additional information, updates and related resources to assist you when billing with NDCs.

CPT copyright 2013 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.

Introducing the BCBSMT Interactive Voice Response (IVR) Phone System

BCBSMT is pleased to offer an interactive voice response (IVR) system - another quick, user-friendly and practical solution to support the demands of your practice. Effective December 2014, this automated voice response system enables you to obtain eligibility and benefits information, check claim status and initiate specific inpatient and outpatient preauthorization requests. The information received through IVR is current and reliable, without the need to wait on hold.

The IVR offers you the convenience of obtaining information quickly and easily. Responses can be requested verbally or by using the innovative alpha touch tone functionality.

Here are just a few benefits of utilizing the IVR:

  • Real-time eligibility, benefit, and claim status responses
  • Confirmation numbers to document each automated quote
  • No wait, fax-back inquiry results
  • No cost to you

Stay tuned! More information will be made available on our Provider website.

Modifier 51 clarification

BCBSMT claims processing systems use code auditing tools to evaluate the accuracy and adherence of reported services to accepted national reporting standards. BCSBMT strives to inform its participating providers when changes or clarifications to those reporting standards are issued. The December 2013 issue of the CPT® Assistant contains a clarification in its Frequently Asked Questions regarding the 51 modifier. The clarification stated that when one of the Chiropractic Manipulative Treatment Codes, 98940, 98941, 98942, is reported for the appropriate number of regions treated with spinal manipulation and code 98943 is reported for extraspinal manipulation, it is not necessary to report modifier 51, as this is a separate and distinct procedure.

Please be aware for claims processed on the new claims software, if a 51 modifier is reported, the allowance for the service will be cutback by 50%, in accordance with the BCBSMT Compensation Policy for modifier 51.

Healthy Montana Kids (Formerly CHIP) Diabetic Supplies

Effective October 1, 2013, Healthy Montana Kids (HMK) changed the way diabetic supplies are administered.

BCBSMT administers the HMK durable medical equipment (DME) benefit. Prior to October 1, 2013, BCBSMT processed diabetic supplies through the pharmacy benefit. Diabetic supplies must now be processed through members' medical benefits as a medical supply and claims need to be submitted to BCBSMT.

Diabetic supply providers may become HMK participating providers by contacting BCBSMT Health Care Services at 800-447-7828, Extension 6100. BCBSMT Health Care Services will explain the participating provider enrollment process and how to submit DME claims for HMK members.

Claims for diabetic supplies such as test strips, lancets, syringes, and needles, will be processed through the medical benefits using the CMS-1500 or UB-04 claim form, whichever you typically use. Claims must be submitted to BCBSMT. If you already submit claims to BCBSMT electronically for other DME, you can use the same process to bill diabetic supplies. If you do not have the ability to submit claims electronically, you need to complete a paper CMS-1500 or UB-04 claim form and mail the form to BCBSMT at P.O. Box 7982, Helena, MT 59604. If you have questions about submitting a claim form, please contact BCBSMT at 855-258-3489.

Healthy Montana Kids Member Health Plan Identification Number Change

HMK is changing member health plan ID numbers effective October 1, 2014. When you provide healthcare services for HMK members after October 1, 2014, please check HMK members health plan ID numbers to be sure you have the new number. HMK Members will receive their new ID cards with updated health plan numbers in June.

Continue to use the HMK member ID card with YDA 802XXXXXX numbers for services provided through September 30, 2014. Beginning October 1, 2014, please start using the updated HMK member ID number that begins with YDE 00XXXXXXX.

This change provides a uniform ID number for HMK Plan members and does not affect HMK member benefits. Thank you for your service to HMK members.

Please Help Reduce Healthy Montana Kids Paid Claim Errors

The Improper Payments Information Act (IPIA) of 2002 (amended in 2010 by the Improper Payments Elimination and Recovery Act or IPERA) requires the heads of Federal agencies to annually review programs they administer and identify those that may be susceptible to significant improper payments, to estimate the amount of improper payments, to submit those estimates to Congress, and to submit a report on actions the agency is taking to reduce the improper payments. The Office of Management and Budget (OMB) has identified Medicaid and the Children's Health Insurance Program (CHIP) as programs at risk for significant improper payments. As a result, the Centers for Medicaid and Medicare Services (CMS) developed the Payment Error Rate Measurement (PERM) program to comply with the IPIA and related guidance issued by OMB.

The PERM program measures improper payments in Medicaid and CHIP and produces error rates for each program. The error rates are based on reviews of the fee-for-service (FFS), managed care, and eligibility components of Medicaid and CHIP in the fiscal year (FY) under review. It is important to note the error rate is not a "fraud rate" but simply a measurement of payments made that did not meet statutory, regulatory or administrative requirements.

Through the PERM program, CMS samples state Fee-For-Service (FFS) CHIP and Medicaid payments, collects documentation from providers, conducts a data processing review on sampled FFS payments, and performs a medical record review on sampled FFS claims.

CMS recovers the federal share of CHIP and Medicaid payments from states on a claim-by-claim basis from the FFS overpayments found in error. CMS also works closely with states to review their error rates, determine root causes of errors, and develop corrective actions to address the major causes of errors.

Last year DPHHS completed CMS's PERM review for FFY 2011. Following are types of errors found by CMS contractor reviews of claims submitted by HMK (CHIP) and HMK Plus (Medicaid) participating providers:

  • Provider records did not support the number of units billed
  • Provider records did not contain provider's signature
  • Provider documentation did not support the claim

In addition to the types of errors listed above, HMK Plus (Medicaid) participating provider claims had the following error:

  • Provider did not validate patient's eligibility for the reviewed program

The CMS PERM review for the current benefit year (October 1, 2013 through September 30, 2014) is in process and CMS's PERM review contractor may be contacting providers and requesting them to submit medical records and/or documentation to support payments made on behalf of HMK (CHIP) and HMK Plus (Medicaid). When providers do not respond to PERM review contractor requests, claims are determined to be paid in error and payment will be reversed.

HMK and HMK Plus programs appreciate the work participating providers do to provide quality health care services for Montana children.

Please keep in mind requirements of recordkeeping and submitting claims in order to avoid potential review findings.

Thank you for providing outstanding medical care for children participating in the HMK (CHIP) and HMK Plus (Medicaid) programs.

Help Reduce Opioid Overuse

In a recent "Vital Signs" article published on its website, the Centers for Disease Control and Prevention (CDC) presents statistics and other information from national sources related to opioid prescribing, which is reaching record levels in some areas of the United States. Increased awareness is critical to help avoid potential misuse that may result in overdose. For ideas on ways you can help, we encourage you to view the article, "Opioid Painkiller Prescribing" on the CDC website at http://m.cdc.gov/en/VitalSigns/opioid-painkiller-prescribing .

The information here is provided for informational purposes only. BCBSMT makes no representations or warranties regarding the CDC website or any information, products or services offered on their website. Questions or concerns regarding the CDC website should be directed to the CDC.

Are you submitting the revised CMS-1500 paper claim form (version 02/12)?

In previous issues of Capsule News, BCBSMT included several reminders about the CMS timeline for implementation of the revised CMS-1500 form (version 02/12). The revised form became effective April 1, 2014, and, as of this date, Medicare discontinued acceptance of the previous version of the CMS-1500 (version 08/05).

In April 2014, a notice on our Provider website announced that, for a limited time, BCBSMT would accept both versions of the CMS-1500 paper claim form to assist providers in transitioning to the revised form.

Please be advised that the dual-acceptance period at BCBSMT is no longer in effect. At this time, all professional paper claims must be submitted to BCBSMT using the revised CMS-1500 claim form (version 02/12).

The previous version of the CMS-1500 claim form (08/05) was discontinued as of April 1, 2014. For more information on the revised CMS-1500 claim form (version 02/12) such as how to order a new supply of printed forms, visit the National Uniform Claim Committee (NUCC) website .

Why not take this opportunity to make the switch to paperless transactions?

As a reminder, if you are not yet submitting claims electronically, now is a great time to start. Electronic claim submission can help streamline your administrative processes, help protect your patients' information and may result in faster claims processing and payment. To learn more, visit the Provider Education/Claims section of our website.

ClaimsXten™ Third Quarter 2014 Updates

BCBSMT reviews new and revised Current Procedural Terminology (CPT®) and HCPCS codes on a quarterly basis. Codes are periodically added to or deleted from the ClaimsXten software by McKesson and are not considered changes to the software version. BCBSMT will normally load this additional data to the BCBSMT claim processing system within 60 to 90 days after receipt from McKesson and will confirm the effective date on the BCBSMT Provider website. Advance notification of updates to the ClaimsXten software version (i.e., change from ClaimsXten version 4.1 to 4.4) will continue to be posted on the BCBSMT Provider website.

Beginning on or after Sept. 29, 2014, BCBSMT will enhance the ClaimsXten code auditing tool by adding two new rules into our claim processing system, as follows:.

Obstetrics Package Rule

This rule audits claim lines to determine if any global obstetric care codes (defined as containing antepartum, delivery and postpartum services) were submitted with another global OB care code or a component code during the average length of time of the typical pregnancy of 280 days and/or pregnancy plus postpartum period of 322 days.

Continuous Positive Airway Pressure or Bi-level Positive Airway Pressure (CPAP/BiPAP) Supply Frequency Rule

This rule audits maximum frequency of PAP supplies based on the recommended replacement schedule from the Centers for Medicare & Medicaid Services (CMS). Specifically, this rule identifies supply codes associated with CPAP/BiPAP therapy that are being submitted by all providers for the same member at a frequency that exceeds the CMS Local Coverage Determination (LCD) policy for PAP supplies. Accessories used with a CPAP device are covered when the coverage criteria for the device are met. If the coverage criteria are met, the accessories billed that exceed the maximum number of supplies for the CPAP/BiPAP item will be disallowed. See below for maximum allowable quantity/frequency guidelines, as determined by CMS:

Procedure Code Maximum Quantity Frequency

A4604

1

90

A7027

1

90

A7028

2

30

A7029

2

30

A7030

1

90

A7031

1

30

A7032

2

30

A7033

2

30

A7034

1

90

A7035

1

180

A7036

1

180

A7037

1

90

A7038

2

30

A7039

1

180

A7046

1

180

BCBSMT will continue with the modifier 59 exempt program through ClaimsXten. This program is based on the Centers for Medicare & Medicaid Services (CMS) National Correct Coding Initiative (NCCI).

NCCI guidelines state, "Each NCCI edit has an assigned modifier indicator. A modifier indicator of '0' indicates that NCCI associated modifiers cannot be used to bypass the edit." BCBSMT will continue to use ClaimsXten as the code pair default. NCCI edits (either Incidental or Mutually Exclusive) that are currently not part of the ClaimsXten database will NOT be added.

Find updates on the ClaimsXten implementation and other BCBSMT news, programs and initiatives. Additional information also may be included in upcoming issues of the Capsule News.

ClaimsXten is a trademark of McKesson Information Solutions, Inc., an independent third party vendor that is solely responsible for its products and services.

CPT copyright 2013 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.

Postponed: ClaimsXten November 2014 Update

(Updated Aug. 7, 2014)

The deployment of the two rules referenced below will be postponed until on or after Dec. 8, 2014.
(The information below was posted previously on our website.)

ClaimsXten™ November 2014 Update

Beginning on or after Nov. 3, 2014, Blue Cross and Blue Shield of Montana (BCBSMT) will enhance the ClaimsXten code auditing tool by adding two new rules into our claim processing system.

The first rule is Medically Unlikely Edit (MUE) of Durable Medical Equipment (DME). This rule identifies claim lines where the MUE value has been exceeded for a CPT/HCPCS code, reported by the same or multiple providers, for the same member, on the same date of service. This rule audits professional claims utilizing the DME Supplier Services MUE table data published quarterly by CMS. The DME Supplier Services MUE table contains assigned MUE values for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS).

The second rule is Durable Medical Equipment (DME) Maximum Payment Rule. This rule calculates the total payments for the DME item being rented to own or for the DME item being purchased new or used and determines if the total payments exceed the plan DME maximum allowance.

BCBSMT will continue with the modifier 59 exempt program through ClaimsXten. This program is based on the Centers for Medicare & Medicaid Services (CMS) National Correct Coding Initiative (NCCI).

NCCI guidelines state, "Each NCCI edit has an assigned modifier indicator. A modifier indicator of '0' indicates that NCCI associated modifiers cannot be used to bypass the edit." BCBSTX will continue to use ClaimsXten as the code pair default. NCCI edits (either Incidental or Mutually Exclusive) that are currently not part of the ClaimsXten database will NOT be added.

Find updates on the ClaimsXten implementation and other BCBSMT news, programs and initiatives. Additional information also may be included in upcoming issues of the Capsule News.

ClaimsXten is a trademark of McKesson Information Solutions, Inc., an independent third party vendor that is solely responsible for its products and services.

CPT copyright 2013 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.

The Affordable Care Act and the Multi-State Plan Program

BCBSMT is participating, along with other Blue Plans, in the Multi-State Plan Program (MSPP). The Affordable Care Act (ACA) created the MSPP to provide consumers with additional health care choices on the Health Insurance Marketplace(s).

What is the MSPP?

The MSPP is operated by the U.S. Office of Personnel Management (OPM) and is designed to increase consumer options on the exchanges. Payers participating in the MSPP are contracted with the OPM. Plans that are approved by the OPM qualify to be sold on the Health Insurance Marketplace(s). MSPP eligibility requirements are similar to that of a qualified health plan (QHP) and plans with standard levels of coverage must be offered.

Are there different steps providers must follow for patients with multi-state plans?

Before rendering services for patients with multi-state plans, you should complete the same steps you follow for any other patients, such as:

  • Ensuring the patient's plan is in the network for which you are contracted;
  • Checking the patient's BCBSMT ID card;
  • Checking the patient's eligibility and benefits by calling the number on the back of member's ID card ; and
  • Helping to ensure patients are referred to in-network providers by using the BCBSMT Provider Finder®.

Capsule News will continue to be a source of information about BCBSMT products and networks. You can also visit the OPM's MSPP web page at http://www.opm.gov/healthcare-insurance/multi-state-plan-program . To monitor the latest announcements, check the Announcements section of our website.

Submitting Electronic Replacement and/or Void Claims

Effective September 1, 2014, BCBSMT will reject replacement/corrected and voided /cancelled claims that do not contain the Document Control Number (DCN) of the original claim you are replacing, correcting, voiding or cancelling. Use the appropriate Claim Frequency Code in CLM05-3 to indicate the claim is an adjustment of a previously adjudicated (approved or denied) claim. The valid claim frequency codes are:

1 Indicates the claim is an original claim

7 Indicates the new claim is a replacement or corrected claim - the information present on this bill represents a complete replacement of the previously issued bill.

8 Indicates the claim is a voided/canceled claim

Replacement Claims

Replacement claims (sometimes referred to as corrected claims) submitted electronically reduce the potential for a claim to deny as a duplicate. Submit the corrected claim electronically with the appropriate claim frequency code (7) in the Claim Frequency Code (2300, CLM05-3) and include the original claim's Document Control Number in the Payer Claim Control Number (2300, REF02*F8).

An example of a replacement claim, along with the required REF segment and Qualifier in Loop ID 2300 - Claim Information, is provided below. The Claim Frequency Code is in red:

CLM*12345678*500***11:B:7*Y*A*Y*I*P~REF*F8*
(Enter the Payer Claim Control Number)

In the above example, "11" (CLM05-1) indicates the place of service on a professional claim. "B" (CLM05-2) is the Facility Code Qualifier, and "7" (CLM05-3) is the Claim Frequency Code.

The replacement claim will replace the entire previously processed claim. Therefore, when submitting a corrected claim, send the claim with all changes exactly how the claim should be processed. Examples:

  • A claim was previously submitted with procedure codes 99213, 88003 and 77090. The 88003 should have been 88004. An electronic replacement claim should be submitted for the line that needs to be corrected, along with the appropriate frequency code: 7, 99213, 88004 and 77090. This indicates to BCBSMT that all charges need to be deleted, and the claim will then be processed with 99213, 88004 and 77090.

Note: If a charge was left off the original claim, please submit the additional charge with all of the previous charges as a replacement claim using frequency code 7. All charges for the same date of service should be filed on a single claim.

Void Claims

If a claim was submitted to BCBSMT in error and should be voided, submit the claim to be voided exactly as it was originally submitted, along with the appropriate claim frequency code (8) to indicate that the claim should be voided and include the Payer Claim Control Number. The Claim Frequency Code is in red:

CLM*12345678*500***11:B:8*Y*A*Y*I*P~REF*F8*
(Enter the Payer Claim Control Number)

Duplicate Claims

Any claim submitted by a physician or provider for the same service provided to a particular individual on a specified date of service that was included in a previously submitted claim. This does not include corrected claims.

Facts About Resubmitting Claims

Before you resubmit a claim because you have not received your payment or a response regarding your payment, stop and think. By sending another claim, you are adversely affecting the claims payment process and potentially creating confusion for the member.

  • By resubmitting your service(s) a second time, we must conduct additional investigative steps which lengthens the claim processing time.
  • If you resubmit a claim, we will ultimately deny the claim as a duplicate.
  • The member will receive multiple EOBs for the same service, often resulting in a call to your office and/or ours.
  • Your staff will spend additional time reconciling the original claim and the duplicate claim.
  • The majority of claims submitted to BCBSMT are processed before 30 days.
  • In fact, most electronically submitted claims are processed within 14 days.

If you have any questions regarding the above information, please contact our Electronic Commerce Center at 800-746-4614.

Medicare Part D Formulary Updates

A summary of recent BCBSMT Medicare Part D formulary changes can be found by clicking here PDF Document. The Blue Cross MedicareRx formulary is updated monthly by our pharmacy provider, Prime Therapeutics*. For a complete formulary listing and for future inquiries regarding prior authorizations, step therapy, coverage determinations/RE-determinations, transition plan benefits, and appointment of representative for your BCBSMT members please refer to the following instructions:

Utilize the following link (https://www.myprime.com ) to access the Prime Therapeutics' Medicare Part D member website:

a) Click on 'Continue without sign in',

b) Follow directions to

  • 'Select your Health Plan' click on 'BCBS Montana'
  • 'Medicare Part D Member?' Select 'YES'
  • 'Select Your Health plan type' 'Blue Cross MedicareRx Value'
  • Select 'Continue to MyPrime'
  • Select 'Find Medicines'

c) From this page you will be able to determine the formulary status and applicable utilization management programs for individual drugs or access any of the important databases outlined above.

*Prime Therapeutics LLC is a pharmacy benefit management company. Blue Cross and Blue Shield of Montana (BCBSMT) contracts with Prime to provide pharmacy benefit management, prescription home delivery and specialty pharmacy services. BCBSMT, as well as several other independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime.

UPDATED! Health Care Management Services Reference Guide

Click here PDF Document.

UPDATED! Alpha-prefix Reference Guide

Click here PDF Document.