When Premera is the secondary payer to Medicare (also known as Crossover
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1 EDI News December 2007 Adjustments and corrected claims will be added to the Crossover process between Medicare and Premera no later than mid- January Feature Articles Crossover Adjustment and Corrected Billing When Premera is the secondary payer to Medicare (also known as Crossover claims) the claims are automatically sent to Premera after Medicare has processed the claims. Claims that are not included in the Crossover process are considered to be an adjustment or a corrected billing. Adjustments and corrected claims will be added to the Crossover process between Medicare and Premera no later than mid-january Once this process is in place you will begin to see these claims reflected on your Medicare Explanation of Benefits (MEOB). Important Note: When a patient has Medicare as their primary payer and Premera as their secondary coverage, claims should not be submitted by the provider to Premera, and more specifically when the MEOB processing message indicates the claim was forwarded (or crossed over) to the secondary payer. Contents Feature Articles page 1 National Provider Identifier (NPI) page 2 Transactional Tips page 3 Payor Updates page 3 EDI Confirmation Reports and Transactions page 4 How to Contact EDI page 5 Holiday Closures page 6 NW Ironworkers, Now Covered by Premera Blue Cross Effective November 1, 2007 NW Ironworkers employees are covered by Premera Blue Cross. The member identification (ID) card issued by Premera to NW Ironworkers will contain an alpha prefix of NXW, preceding the member ID. Be sure to batch your NW Ironworkers patient electronic claims for Premera, to prevent delay in processing and/or payment of these claims. Should you have any questions regarding this change, please contact the Premera EDI Team at EDI News Letter - Going Green In efforts to go green, Premera will be mailing the quarterly EDI News letter link to you beginning March This will allow you to access the newsletter online, rather than receiving a paper copy. To make sure you are able to receive the EDI News , please send us your address to edi@ premera.com. Please indicate in the body of your Here is my address for the following provider office, please provide the name of the providers office and your EDI submitter ID if known. December 2007 Washington EDI News 1
2 National Provider Identifier (NPI) Premera NPI Update, Get it, Register it, Use it! Premera currently processes electronic claims for providers that include both NPI with Tax ID or Tax ID only. If you are submitting an NPI for the Billing or Pay To provider, the Tax ID is still required per the 837 HIPAA Standard Implementation Guide. The Centers for Medicare and Medicaid Services (CMS) previously announced the compliance date remained May 23, 2007 for the use of NPI in all standard electronic transactions, including claims submission, however a contingency plan was announced. Covered entities* are allowed to implement a contingency plan for up to a 12- month period during which they can accept either the NPI or legacy ID. Each covered entity determines contingency use and duration however, the duration cannot exceed May 23, We will continue to monitor utilization of NPI to determine contingency duration for Premera. Register your NPI at to share your NPI with Premera and other participating health plans. To view additional information regarding the NPI mandate, including a comprehensive question and answer document, visit provider * Under HIPAA a covered entity is a health plan, a health care clearinghouse, or a health care provider who transmits any health information in electronic form in connection with a HIPAA transaction. NSF T0301 Accepts NPI We have implemented changes to accept NPI within the NSF T0301 format. Specifications for NSF T0301with NPI changes are posted at (select Providers, Electronic Claims and then Formats), or you may contact EDI to obtain a soft or hard copy. Following is a summary of the changes: w Payor legacy provider number fields remain unchanged, and are not to be used for the NPI. w New or existing previously unused fields have been defined specifically for NPI Qualifier and NPI Identification usage. w The Billing (BA0) and Pay-To (BA1) records require that you include your Tax ID when using the NPI fields. Testing of your changes containing NPI is required. Most systems will require a software upgrade from your vendor. Once you have made the necessary changes and/or required upgrades to your system to send the NPI within the NSF T0301 format, please contact EDI to notify us of your testing plan, at , or by at edi@premera.com We look forward to working with you to implement your NPI changes. 2 December2007 Washington EDI News
3 Transactional Tips Bill Your Secondary Claims Electronically Providers using the ANSI X electronic format can bill Premera secondary claims electronically by providing the following information: w Primary Payer Name w Primary Payer Member ID for the patient w Primary Payer Allowed Amount w Primary Payer Payment Amount w Primary Payer reason for nonpayment (i.e., non-covered service, applied to deductible, benefit max, etc.) w Primary Payer Adjudication Date for claim is required Note: The NSF T0301 electronic format does not support billing Premera secondary claims electronically. Premera secondary to Medicare claims are automatically sent to Premera by Medicare after Medicare has processed the claim. To prevent duplicate claim submission, please do not bill these claims to Premera if your Medicare Explanation of Benefits indicates the claim was forwarded (or crossed over) to the secondary payer. Call the EDI Team at with questions or for additional information to begin billing your Premera secondary claims electronically. Emdeon Payor Listing We encourage you to obtain the most recent payor listing directly from Emdeon (formerly known as WebMD) on a monthly basis at: w Page down to (Payor Lists) on right hand side w Page down to (HIPAA Payor List) w Choose (COMMERCIAL) from Option List on left hand side Any payor ID that includes alpha and numeric values with the exception of Tricare (SCWI0) and HMA (TH049) defaults to zeros and will reject at Emdeon. A hardcopy listing of this information is available. Contact any of our EDI representatives for a payor listing. Questions regarding the listing should be directed to the Emdeon Payor List Help Line at or their help desk at EDI Notification Process We have implemented an notification distribution process to improve our communication with our Trading Partners. Please us at EDI@Premera.com or call us at with your address, Tax ID, and Submitter ID to add your information to this notification list. EDI@Premera.com Payor Updates Railroad Medicare Claims Need Critical Review Medicare (CMS) is urging providers and billing agents to submit all claims to Medicare contractors electronically. Due to this, the Premera Clearinghouse is experiencing an increase in the number of claims we receive and forward to Palmetto GBA, the Railroad Medicare contractor. Along with that increase in claims, we are also seeing an increase in the number of rejected claims in the Railroad Medicare processing. Response Reporting from Railroad Medicare regarding these rejected claims must be handled manually by Premera Clearinghouse EDI staff, as the report does not lend itself to automated processing for electronic distribution. Please take special care in the preparation and submission of your electronic claims. Submitters that consistently submit claims that reject in the Railroad Medicare process may temporarily lose production privileges for this payor. This would require a testing process prior to being returned to production status. Thank you for your efforts to ensure submission of error-free claims. December 2007 Washington EDI News 3
4 EDI Confirmation Reports and Transactions Clearinghouse Reports Downloading the various clearinghouse reports from Secure Transport (ST) will help you avoid lost claims and eligibility errors. The reports contain rejected claim information. Verifying these reports against your office reports ensures accurate tracking of your claims. Please remember the following key points: Reports are only available online via ST. Retrieving (downloading) your reports regularly ensures notification that we have received your claims or if there were any rejections. Rejected claims are not processed; they must be corrected and re-billed. Electronic Claim Transaction Report (BCWARPT) Availability These reports are available for all electronic claim submitters regardless of claim format. On-line reports are available after 6 a.m. each day and contain claims processed as follows: - Files received by 3 p.m. Monday through Friday are processed in that day s cycle with the reports available the following morning. - Files received after 3 p.m. are processed the next working day with the reports available the following business day. These reports are your only notification of claim receipt or of any rejections. Six generations of reports are available: - The most recent transmission report is named BCWARPT. Older previous transmission reports are named BCWARPT1 through BCWARPT5. (For each report file there is a compressed (.EXE) and an uncompressed version). 837 Transaction Error Report (ANSI X12 Submitter): The 837 Transaction Error Report was developed to report claims that reject in the HIPAA validation process. This report provides detailed information regarding the HIPAA validation errors. Claims rejected at this level do not appear on any other report and must be corrected and re-transmitted. Note: To correctly balance files transmitted to our Clearinghouse you will need to reference both the Electronic Claim transaction report (BCWARPT) and the 837 Transaction Error Report to reflect a full accounting of the claims transmitted to Premera. For assistance, please contact an EDI Representative. Contact your software vendor for assistance in interpreting this report. The following are other payor reports available to you in your ST Download Directory Noridian Medicare Reports The Nordian report file names are: Claims Confirmation Report Batch Detail Control Listing CHNORA.NEW CHNORB.NEW (Uncompressed version) (Uncompressed version) CHNORA.EXE (Compressed version) CHNORB.EXE (Compressed version) Additional (archived) generations of the on-line reports will be available from previous transmissions, and will be numbered from most recent to oldest, such as: CHNORA.1 through CHNORA.99 (Uncompressed version) CHNORA1.EXE through CHNORA99.EXE (Compressed version) THIN Reports, include WA Regence Blue Shield and Asuris NW Health The THIN report file names are: CHTHIN.NEW (Uncompressed version) CHTHIN.EXE (Compressed version) Additional (archived) generations of the on-line reports will be available from previous transmissions, and will be numbered from most recent to oldest, such as: CHTHIN.1 through CHTHIN.99 (Uncompressed version) CHTHIN1.EXE through CHTHIN99.EXE (Compressed version) Please use the following steps to download your response report files: Secure Transport (ST) users: 1. Go to your Download Directory. 2. Highlight the appropriate report file. 3. Select Download 4. Report file will be downloaded to the appropriate report directory on your PC. ST is available 7 days a week, 24 hours a day 997 (Functional Acknowledgement ANSI X12 Submitters): The 997 is found in the ST Download Directory. It is the responsibility of each provider office to download their 997 after every file transmission The 997 is available within one hour of transmitting the file If any portion of your file does not pass HIPAA validation or contains other errors, all or part of the file may be rejected and reported on the 997. December 2007 Washington EDI News 4
5 Contact EDI Trading Partner Information Update Request Please contact an EDI representative whenever you update your software vendor, billing service, billing staff, office address or Tax ID so that we can update your records and prevent delivery disruption of your 835 Electronic Remittance Advise (ERA) and electronic reports. How to Contact EDI If you have questions or wish to obtain information about any of the articles in this newsletter, please call one of the EDI representatives listed below: Phone hours: 8 a.m. 5:00 p.m. (PST), M-F Toll-free Select Option 1 for Seattle (Mountlake Terrace) office Select Option 2 for Spokane office Select Option 3 for Bend office w Fax numbers: Seattle (Mountlake Terrace) office: Spokane office: Bend office: w Questions or problems: the EDI department at EDI@premera.com. w Premera health plan information: Use our Web site at Mountlake Terrace office Direct Lines Lynnette Boulch Lenea Dyer Liza Franzen Linda Hunt Patricia McCabe Rowena Solomon Dana Thomas Spokane office: Toll-free Beth Passmore Shari Johnson Bend office: Alex Dufault Leana Morton December 2007 Washington EDI News 5
6 P.O. Box 327 Seattle, WA PRESORTED STANDARD U.S. POSTAGE PAID SEATTLE, WA PERMIT NO Please post or circulate this newsletter in your office Holiday Closures 2007 Premera will be closed on the following dates: Thursday, November 22 - (Thanksgiving Day) Friday, November 23 - (Day after Thanksgiving) Monday, December 24 - (Christmas Eve) Tuesday, December 25 - (Christmas Day) EDI News EDI News is produced quarterly to provide important information related to electronic claims processing for the office billing staff, billing services and software vendors from Premera. Please keep this newsletter for future reference. Editor: Lenea Dyer Phone: , Fax: lenea.dyer@premera.com The EDI team is dedicated to providing excellent service. 6 December 2007 Washington EDI News ( )
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