The transition to standard claims

Transcription

1 June 2004 Schedule your transition to the standard HIPAA claims transactions today. Contents HIPAA Contingency Update page 1 Medicare Update page 1 Electronic Billing Hints page 2 Clearinghouse Services page 3 Group Health NW Claims page 3 BBS Reports page 4 BBS Availability page 5 WebMD Payer Listing page 5 Office Updates page 5 Holiday Closures page 5 HIPAA Contingency Plan Update The transition to standard claims transactions is continuing slowly not only for Premera, but for the industry as a whole. Premera will continue with dual support of both nonstandard and standard electronic claims transactions, as outlined in our News Brief of March 15, 2004, and EMC Hotline of April We will continue to monitor Centers for Medicare and Medicaid Services (CMS) guidance on industry readiness. The Premera contingency plan may be altered once we attain an acceptable rate of standard transactions. However, we will do our utmost to give you 30 days advance notice of the date we will no longer support nonstandard electronic claims transactions. Although we continue to accept nonstandard claim transactions today, if Medicare Update The EDI Support Services at Noridian Administrative Services recently sent a notification outlining the payment cycle for electronic claims submitted after June 30, 2004, as follows: On February 27, 2004, CMS announced a modification of the HIPAA contingency plan implemented by Medicare on October 16, Specifically, the announcement stated that Medicare would continue to accept claims electronically in a pre-hipaa format on or after July 1, 2004, but such claims would not be eligible for Medicare payment until the 27th day after receipt, at the you have not contacted the EDI Department, we encourage you to do so to discuss and schedule your transition to the standard HIPAA claims transactions. We also encourage you to contact your practice management system vendor or clearinghouse if applicable, to clarify their HIPAA contingency plans and their plan for migrating to the standard transaction format. Thank you for working with us as we move forward with adopting and adhering to HIPAA regulations. If you have questions not answered by the EMC Hotline or do not have Web access, please contact an EDI Representative for assistance at earliest. All electronic claims today are eligible for payment 14 days after receipt. This modification of the HIPAA contingency plan was intended to give providers additional time to become HIPAA compliant, but was also a measured incentive to end the contingency plan for all incoming Medicare claims. If you are not sending your claims to the Premera Blue Cross (PBC) Clearinghouse in the ANSI X Addenda or the NSF-H (T0301) electronic formats, please contact your vendor immediately to make this change to prevent delay in your Medicare reimbursements. An Independent Licensee of the Blue Cross Blue Shield Association June 2004 EMC Hotline 1

2 Billing Valid Special Characters In any name or address field, use of special characters is restricted to those shown in the list below. Use of characters other than those in the following list, may result in claim rejections. This list is based on Noridian Medicare edits and contains valid characters that can be used in subscriber, patient, provider or clinic name and address fields. Please be aware: specific payers may have additional requirements. As we become aware of other restrictions or requirements, they will be added to the editing process and communicated to you. A-Z a-z (A dash or hyphen) / (forward slash). (period), (comma) & (ampersand) (single quote) (double quote) (space) The first position in the field must contain A-Z, a-z, or 0-9. DSHS Referring Provider Information For providers submitting DSHS claims to the Premera Blue Cross Electronic Claims Clearinghouse, the referring information must be included in the claims in one of the following ways: Note: This information applies to DSHS claims only. ANSI X A1 837P submitters Claim Level Referring Provider Loop 2310A REF02 must contain the qualifier 1D and REF02 must contain the DSHS provider number of the referring provider. Line item referring provider Loop 2420F REF01 must contain the qualifier 1D and REF02 must contain the DSHS provider number of the referring provider. Loop 2000B SBR03 (Group Number) must be blank for all Medicare claims. Loop 2000B SBR04 (Group Name) must be blank for all Medicare claims. 2 June 2004 EMC Hotline For Physicians and Providers Electronic Billing Helpful Hints This is a new section of the EMC Hotline dedicated to troubleshooting electronic claim issues and preventing claims rejections. Please watch for new important billing information in each issue of EMC Hotline. NSF_T0301 submitters Option 1 - Place the DSHS provider number of the referring provider in EA0.20. Qualify the number by placing 1D in EA Note: The referring provider name fields EA0.24 and EA0.25 must be filled when EA0.20 is used. Option 2 - Place the DSHS provider number of the referring provider in EA0.21. It is not necessary for you to include the qualifier. PBC examines the content of EA0.21 and if the field contains a 7-digit numeric value, the qualifier 1D is forwarded to DSHS. Note: The referring provider name fields EA0.24 and EA0.25 must be filled when EA0.21 is used. Option 3 - Place the DSHS provider number of the referring provider in FB1.13. It is not necessary for you to include the qualifier. PBC examines the content of FB1.13. If the field contains a 7-digit numeric value, the qualifier 1D is forwarded to DSHS. Note: The referring provider name fields FB1.10 and FB1.11 must be filled when FB1.13 is used. Option 1 is the preferred solution but option 2 or 3 will allow you to submit compliant information. All Types of Claims Printed as hardcopy claims (carrier code 9999) batches may not contain multiple payer claims in one batch. If this occurs it causes invalid claims information to be sent to the payer. Separate batches are required for each insurance company being billed. Referring Provider Information Edits New edits for claims with referring provider information have recently been implemented for NSF-T0301 submitters. Similar edits were already in place for ANSI X A1 837P submitters. The new edits check to make sure that if referring provider information (either name or number) is included in the claim, all required fields are populated. When EA0.20 or EA0.21 contains the referring provider number, the referring provider name fields EA0.24 and EA0.25 must be populated. Continued on page 3

3 For Physicians, Providers and Office Staff Electronic Billing Helpful Hints Continued from page 2 When the referring provider name fields EA0.24 and EA0.25 are filled, the referring provider number must be included in EA0.20 or EA0.21. When FB1.13 contains the referring provider number, the referring provider name fields FB1.10 and FB1.11 must be populated. When the referring provider name fields FB1.10 and FB1.11 are filled, the referring provider number must be included in FB1.13. ICD-9 Diagnosis Codes Claim level rejections frequently occur due to invalid diagnosis codes billed. Please be sure and include the correct ICD-9 diagnosis codes including the 4 th and 5 th digit whenever applicable. Billing Provider Credentials To avoid claims processing delays, if you include provider credentials on your electronic claims, please insure you do not place them in the last name field. Updated NSF_T0301 Manual Available The NSF_T0301 specification manual has been updated and is available on the Premera Blue Cross Web site at Group Health NW Claims Trading partners who bill Group Health claims (Payer ID and 91121) will notice that these claims are now reflected on the Electronic Claims Transaction Report under a heading of Group Health NW. Premera Blue Cross Clearinghouse Services Only professional ANSI X and NSF T0301 claims submitters will be offered PBC clearinghouse services. Note: if you are a clearinghouse submitting electronic professional claims to the PBC clearinghouse, you are allowed to submit PBC products only. How to Contact EDI Fax numbers: Mountlake Terrace office: Spokane office: For questions or problems: the EDI department at EDI@premera.com. For information on Premera health plans: Use our Web site at Connection issues: If you have questions regarding your connection to Premera, call the Network Coordinators, Cindy Carmichael or Val Cochran at Be sure to have your submitter ID number ready for them so they can better assist you. 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 coverage is available between 8 a.m. and 4:30 p.m. (PST) Monday through Friday. Direct Lines Mountlake Terrace office Toll-free Lynnette Boulch Teresa Busch Lenea Dyer Linda Heitman Norma Seymour Rowena Solomon Norma Seymour Dana Thomas Spokane office: Toll-free Joan Ruyle Larry Stansbury June 2004 EMC Hotline 3

4 For Physicians, Providers and Office Staff Bulletin Board System (BBS) Reports To avoid lost claims, eligibility errors and missing rejected claim information, you must download the Electronic Claims Transaction Report from the PBC Bulletin Board System (BBS). Verifying these reports against your office reports ensures accurate receipt of your claims. Please remember the following key points below: Reports are available online from the BBS only! PBC does not mail printed reports. Please make sure to pick up reports regularly. This is your only notification that PBC has received your claims and whether there were any rejections. Important Reminder: Rejected claims do not enter the PBC processing system. Claims that reject must be corrected and re-billed. ANSI X12 Submitters There are a total of three reports outlined below for ANSI 837X12 Addenda submitters to download from the Bulletin Board System (BBS). One: 997 (Functional Acknowledgement) The 997 is found under menu selection <2> Non- Medicare ANSI X12 Transaction Download. It is the responsibility of each provider office to download their 997 after every claims transmission. The 997 is normally available within one hour of claims transmission. In the event 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. Contact your software vendor for assistance in interpreting this report. Two: 837 Transaction Error Report ANSI Transaction reports are available for downloading from the BBS under Menu option <A> ANSI X12N Transaction Downloads. The following menu selections are available: <1> Medicare Part-A ANSI X12 Transaction Download <2> Non-Medicare ANSI X12 Transaction Download <3> Non-Medicare ANSI Error Report Download Note: To correctly balance files transmitted to PBC Clearinghouse you will need to reference both the Electronic Claim transaction report (ECC16000) and the 837 Transaction error report to reflect a full accounting of the claims transmitted to PBC. For assistance, please contact an EDI Representative. If no 837 Transaction error report is available to download claims were received without any validation errors. This report is found under menu selection <3> Non- Medicare ANSI Error Report Download. 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. This report is created only when HIPAA validation errors are detected your 997 will show rejections. Claims rejected at this level do not appear on any other BBS report and must be corrected and re-transmitted. The 837 Transaction Error Report is provided online for retrieval from the Premera Blue Cross (PBC) Bulletin Board System (BBS) in a PDF format. The report file name is 837ERnnn.PDF (example: 837ER001.PDF). The 3 positions following 837ER denotes the generation of the report. At this time only a non-compressed version of the report is available. In order to view and print this report you will need Adobe Reader. If your computer does not have Adobe Reader, it can be downloaded for free from Adobe at: Three: Electronic Claim Transaction Report (ECC 16000) To correctly balance files transmitted to the PBC clearinghouse you will need both the 837 Transaction error report (if applicable) and the Electronic Claim Transaction Report (ECC 16000). For any questions, please contact an EDI Representative for assistance at June 2004 EMC Hotline

5 For Physicians, Providers and Office Staff Healthy Options and Basic Health Plans Medicaid Claims The transfer of our Healthy Options and Basic Health business to Molina Healthcare of Washington, Inc. is proceeding well. To help you during this transition, please note the following: For claims with dates of service through May 31, 2004, continue to bill electronically to Premera with Carrier Code WA14 (even if the discharge date on an inpatient claim is June 1, 2004, or later). Claims with a beginning date of service of June 1, 2004, or after can be billed electronically to Premera for Molina, but under Envoy WebMD with Carrier Code 0000 and a Payer ID number of General Information BBS System Availability The (BBS) is available 24 hours a day, 7 days a week, except for Monday - Friday 3 to 4 p.m. (PST). Please note: 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 morning (2nd day after receipt). Online reports are available after 6 a.m. each day. Please Help Us with Office Updates Any time you have a change in your software vendor, billing service, billing staff, or office addresses, please contact an EDI representative to update your office information. WebMD Payer Listing We encourage you to obtain the most recent payer listing directly from WebMD Envoy on a monthly basis by either accessing their Web site or calling their fax-on-demand service. To download the Medical Participating Payer list, go to or To obtain a fax copy, simply call and request document #31. WebMD will fax it to your office immediately. You may also obtain a copy from our office by contacting any of our EDI representatives. For any further questions, call WebMD Payer List Help Line at or their help desk at Holiday Closures Premera will be closed on: July 5 September 6 Independence Day Labor Day June 2004 EMC Hotline 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 EMC Hotline (Electronic Media Claims) comes out quarterly to provide important information relating to electronic claims processing for the office billing staff, billing services and software vendors from Premera Blue Cross. We strongly recommend you keep this newsletter for future reference. Editor: Teresa Busch , ext Fax: The Premera Blue Cross EDI team is dedicated to providing excellent service, and we appreciate your continuing efforts to submit error-free claims. 6 June 2004 EMC Hotline ( )