Claim Tips for Health Care Providers
At Blue Cross and Blue Shield of Oklahoma, we are committed to fast and efficient claim processing. In order to prevent delays, billing errors and other potential setbacks, we’ve put together valuable tips and information to help you manage and submit claims.
Some helpful guides for filling out claim forms:
- CMS-1500 User Guide — This guide will help providers complete the CMS-1500 (08/05) form for patients with Blue Cross and Shield of Oklahoma insurance.
- UB-04 User Guide — This guide will help providers complete the UB-04 form for patients with Blue Cross (facility) coverage.
Physicians and professional providers who have received an approved predetermination (which establishes medical necessity of a service) do not need to submit additional medical records to Blue Cross and Blue Shield of Oklahoma. In the event that additional medical records are needed to process a claim on file, a request will be made at that time.
The three character alpha prefix at the beginning of a member’s ID number is key to identifying and correctly routing out-of-state claims to the appropriate Blue Cross and Blue Shield (BCBS) Plan. These letters identify the plan to which the member belongs and are key to confirming eligibility/coverage.
Please note that an incorrect or missing alpha prefix can cause unfortunate delays in the processing of a claim. Complete patient information allows claims to process as quickly as possible. Below are some helpful tips related to the alpha prefix:
- The alpha prefix is always three letters, followed by the member’s ID number, which can be six to fourteen characters total.
- Always include the correct alpha prefix, and avoid randomly selecting an alpha prefix.
- Include the alpha prefix and all alpha numeric characters on all correspondence and claims submitted to the BCBS Plan.
- Make copies of the member’s ID card (front and back) for your records.
Are you a provider billing corrected claims on services provided to a Medicare primary member? If you answered “yes” to this question, BlueCross and BlueShield of Oklahoma (BCBSOK) is here to help you.
When physicians and/or facilities find it necessary to file corrected claims on services for a Medicare primary member, the corrected claims should be filed direct to Medicare, not BCBSOK. By filing the corrected claims to BCBSOK, your claims may be delayed in processing and/or may result in a denial stating the claim either must be filed to Medicare or the claim is a duplicate to the original claim. BCBSOK has noticed an increase of Medicare primary corrected claims being filed incorrectly to BCBSOK rather than directly to Medicare.
When physicians and/or facilities see an out of state Medicare primary member, often times that claim is sent directly to the member’s home plan for secondary processing by Medicare after primary processing has been completed. This is known as a Medicare crossover. Physicians and/or facilities should follow the same process for filing corrected claims for Medicare primary members just as if filing the claim for the first time to Medicare.
Medicare will process the corrected claim and forward that claim direct to the member’s home plan for secondary processing. The physician and/or facility can determine if the claim has been forwarded to the member’s home plan by reviewing the Explanation of Medicare Benefits (EOMB). The EOMB will indicate “Crossover” or “XOVER” which tells the physician and/or facility that the claim was submitted to the member’s home plan for secondary processing.
If you have any questions, you may contact our Provider Customer Service Department at (800) 496-5774 to speak with a Customer Advocate for assistance.
Effective November 21, 2008, medical doctors/doctors of osteopath (MDs/DOs) may file a Post-Service Provider Appeal to resolve disputes limited to the application of coding and payment rules and methodology related to Claims Adjudication Guidelines, bundling, modifiers, etc. Blue Cross and Blue Shield of Oklahoma’s internal appeal process must be exhausted before an external appeal will be considered. The provider appeals are conducted by an independent review organization, MES Solutions.
An appeal can be submitted via Web, fax or mail. The guidelines for submitting an appeal and the applicable fees can be found on MES Solutions' Web site .
To Verify BlueCard Eligibility and Benefits
- Ask members for their current member ID card and verify the member's ID number. The ID number begins with the three-letter alpha prefix followed by a combination of 6 to 14 letters/numbers.
- Check eligibility and benefits online by submitting a HIPAA 270 transaction (eligibility) to BCBSOK through Availity® or call the BlueCard Eligibility Line at (800) 676-BLUE (2583).
To Submit BlueCard Claims
- Submit all Blue Plan claims to BCBSOK.
- Include valid alpha prefixes. Claims with incorrect or missing member ID numbers cannot be processed.
- If there is more than one payer and a Blue Plan is primary, include Other Party Liability (OPL) information on the claim.
- Do not send duplicate claims.
Participating providers shall adhere to the following policies with respect to filing claims for covered services to Blue Cross and Blue Shield members:
- A Provider performing covered services for a Blue Cross and Blue Shield member shall be fully and completely responsible for all statements made on any claim form submitted to BlueCross and Blue Shield of Oklahoma (BCBSOK) by or on behalf of the Provider. A Provider is responsible for the actions of staff members or agents.
- BCBSOK considers fraudulent billing to include, but not be limited to the following:
- deliberate misrepresentation of the services provided to receive payment for a non-covered service;
- deliberately billing in a manner which results in a reimbursement greater than what would have been received if the claim was properly filed; and/or
- billing for services which were not rendered.
- Provider shall not bill or collect from a member, or from BCBSOK, charges itemized and distinguished from the professional services provided. Such charges include, but are not limited to, malpractice surcharges, overhead fees or facility fees, concierge fees or fees for completing claim forms or submitting additional information to BCBSOK.
- A Provider is prohibited from paying or receiving a fee, rebate or any other consideration in return for referring a Blue Cross and Blue Shield member to another provider or in return for furnishing services to a member referred to him or her.
- Every BCBSOK member shall be supplied with an appropriate identification card and participating providers shall be entitled to require members to present their identification card when services are requested. It is recommended that photo identification be required each and every time services are provided.
- Standard BCBSOK benefits are not available for services rendered by Providers to their immediate family members. Therefore, BCBSOK does not expect to receive claims for these services.
- A Provider who refers a member to another provider who does not participate in the member's PPO network, must disclose that fact to the member in writing and advise the member that they may incur higher deductibles or copayments and may be responsible for charges which exceed the allowable charges for network providers. Also, a provider who refers a member to a facility or other provider in which the referring physician has an ownership interest must disclose that interest in writing to the member.
The provider should submit properly filed claims for services using either the CMS-1500 or the UB-04 paper claims form and subsequent revisions, or submit claims electronically. All information necessary to adjudicate the claim, including appropriate codes, must be provided.
Blue Cross and Blue Shield of Oklahoma
P.O. Box 3283
Tulsa, OK 74102-3283
Box 14 should always be filled out. It is based on the patient’s current services. We use this date to determine if the service is an emergency.
Box 15 is only used if the policy indicates there is a pre-existing waiting period. You can verify this by calling 1-800-972-8088 and selecting “eligibility.” If the quote indicates there is a pre-existing waiting period, you must fill in this box. We use this date to determine pre-existing conditions. Use the date the patient was seen for the first time, for this condition, even if seen by another.
View an example of the claim form date boxes .
End Stage Renal Disease (ESRD) is a condition of kidney failure requiring dialysis (a treatment that cleans the blood when the kidneys do not work) and /or kidney transplants. ESRD patients may be eligible for Medicare regardless of their age, employer group size, or employment status (i.e. retired).
If the members Group Health Plan is primary because of disability, age, etc, other than ESRD, then the Group coverage will continue to pay primary during the first 30 (for home dialysis) or 33 (for center dialysis) month coordination period from the 1st date of dialysis. Once the coordination period has been completed, then Medicare becomes primary. If Medicare has been deemed primary because of a disability, age, etc and THEN the member develops ESRD, Medicare will remain primary and the ESRD guidelines will not be applicable. Medicare remains primary in this situation only.
In addition, if a kidney transplant occurs during the coordination period, the Group Health Plan will continue to pay primary until the 30 or 33 months have been completed. Once the coordination period has been completed and Medicare becomes primary and a transplant occurs during this time, Medicare will remain primary for 36 months from the transplant date. If the transplant is a success after the 36 months then the Group Health Plan would then again become primary.
Our system will identify members with ESRD and store their Medicare coverage information. It is the provider’s responsibility to determine who the primary carrier is and track the coordination period.
Duplicate claims can be very costly for health care providers and health insurers, as every time a duplicate claim is filed, it must be processed. This can be counterproductive in the following ways:
- Time is taken in the claims processing system that could be used to process claims already loaded to the system.
- Valuable staff time is used to track duplicate claims and reconcile the system for BlueCross BlueShield of Oklahoma (BCBSOK).
- Provider office staff loses office time completing and submitting the second claim.
- Providers may be paying a billing service to resubmit a claim that was already in process to pay within a few days.
Provider Claim Summaries (PCS) provide details regarding how claims were adjudicated by BCBSOK. The PCS includes claim payment disposition along with any denial reasons, and also will include a ledger that gives a description of the denial reasons for each claim.
Below are some of the top reasons why duplicate claims are submitted (including some helpful tips and reminders to reduce the number of duplicate claim submissions):
- A claim has not been paid and a duplicate claim is submitted.
In the case of electronic claims, the reports received by a provider’s office will indicate if a claim is in process or if action is needed on the provider’s part. If the claim is in process, resubmitting will not speed payment. In fact, it will delay payment as the duplicate is researched. In addition, this can be costly if the billing cycle automatically resubmits the claim within a specified time period. Effectively using the reports generated and/or the Availity website for claim status will make filing additional claims unnecessary in most cases. The Availity website can also be used for claim status regarding paper submitted claims.
- A claim was rejected for additional information.
If a claim is rejected requesting additional information, another copy of the claim along with the information requested is not required. BCBSOK already has the claim copy on file. When submitting the requested information, please include a copy of the original request. (Note: If a claim is rejected needing corrected information on the claim itself, then a corrected claim copy will need to be submitted.)
- Payment has been received but not posted to show the claim is paid.
It is very important to process all reports and checks promptly once they reach the provider’s office. A significant number of Customer Service calls involve A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association payments already made by BCBSOK. This information can also be verified on the Availity website.
At BCBSOK, we are committed to paying all claims as promptly and accurately as possible. We are asking for our providers’ help in reducing duplicate claim submissions and allowing our systems to work to their full capacity, processing current claims on the first submission.
Electronic Claim Submission-Maximizes Claim Processing
Electronic claim submission maximizes claims processing efficiency and paper submissions do not. Any claim that can be submitted on paper can be submitted electronically. If you need more information on how to submit claims electronically call 1-800-AVAILITY (282-4548) or log on to Availity.
Advantages of Submitting Claims Electronically
The information required to file electronic claims is the same as for paper claims but there are major advantages to submitting electronic claims versus paper claims:
- You have better control and accuracy. Electronic claims are entered in the BCBSOK’s computer system just the way they leave your office. There is no need to worry about a claim being delayed or denied because it is not legible.
- You know when your claims are received because your office receives special reports detailing which claims were accepted and if there is a problem you can correct it before the claim is processed.
- You are able to reduce your overhead; electronically submitted claims can save hours of clerical time. You do not have to spend time typing, stapling, stamping and mailing.
What To Submit Electronically
As a guideline, the following claims may be submitted electronically:
- All original claims
- All BlueCard (out-of-state) claims
- Late Charges (Use appropriate indicator.)
- Corrected Claims (Use appropriate indicator.)
- Duplicate Claims (Use appropriate indicator.)
- Medicare Supplemental Claims that do not automatically crossover.*
* If your Medicare B Remittance Advice or electronic RA does not indicate the claim was forwarded to BCBSOK. Do not submit attachments or Explanation of Medicare Benefits (EOMBs) unless requested by the claim processing unit.
Disadvantages of Submitting Paper Claims
- The chances that your paper claims will be manually keyed due to form deviation are very high. There is great variety in the UB-04 and CMS 1500 forms that we are receiving. When the form that you are using is not up to US Government Printing Office specifications, the claim must be manually processed and will be delayed.
- Once the claim has to be manually keyed, there is an increased potential for error due to undecipherable text and manual intervention.
- You should never routinely file a paper claim as an exact duplicate of an electronic claim. This second (tracer) claim creates additional investigation for both claims which lengthens the claim processing time and ultimately delays payment.
NOTE: You should carefully review your electronic claim response reports to ensure that all of your electronic claims were accepted into our system. Rejected claims should be corrected and resubmitted electronically. Resubmission of claims accepted into our system will cause the new claim to be rejected as a duplicate and delay the entire adjudication process. Using our automated claims inquiry functions for claim inquiries will provide verification that your claims have been accepted and are in the processing system.
Upon a recent review of claim denials we have identified the most common issues that can cause delays in claims processing.
Here are a few tips to keep in mind when filing claims:
- Verifying benefits can be helpful prior to submitting claims or appeals in order to have the most current policy information as well as any benefit exclusions that may be relevant to the services being rendered.
- Obtaining a copy of the member’s current insurance card at all visits, as policies can often change. This will ensure that the claims are submitted with the most current policy information.
- Verifying the correct alpha prefix is on all claims — this is extremely important. Many claims cannot be processed without the member’s alpha prefix.
- If there are two BlueCross BlueShield insurance policies for a member, please be sure to include both the primary and secondary policy information on the claims.
- If a corrected claim is needed, it must be marked as “corrected claim”, and indicate what is being corrected. If the corrected claim is not marked as such, it may be denied as duplicate or the issue may not be resolved appropriately.
- Be sure to include all current and complete provider information on the claims, including the current tax identification number and NPI numbers in the correct fields.
- If a response has not been received to a claim, please contact Customer Service at (800) 496-5774, or check the Availity website for claim status prior to resubmitting the claim. If the claim is already on file but has not yet been processed, a resubmission will not expedite the processing of the original claim.
You can save additional time by viewing our tips for processing claims with one insurance carrier .
Confirming member benefits and eligibility prior to rendering services will save your office valuable time and money. Many dollars and staff hours are lost chasing down denials on the back end when they could have easily been avoided. Your office, as well as our Blue Cross and Blue Shield of Oklahoma (BCBSOK) member, will also have a better understanding of what the member’s responsibility will be for the services rendered.
Benefits and eligibility may be obtained online through Availity at no charge to you. Included will be covered services, co-pays, and deductibles. Did you know that benefits for out of state members are also provided online through Availity? You may also contact BCBSOK Provider Customer Service at 800-496-5774 and use our IVR automated system.
Preauthorization is required for certain types of care and services. In Oklahoma, it is the responsibility of the provider to confirm that preauthorizations are obtained for services requiring preauthorization. Preauthorization must be obtained for any initial stay in a facility and any additional days or services that are added on.
If preauthorization is not obtained for initial facility care, or services/additional days or services that are added on, the benefit for covered expenses may be reduced.
Preauthorization does not guarantee payment. All payments are subject to determination of the insured person's eligibility, payment of required deductibles, copayments and coinsurance amounts, eligibility of charges as covered expenses, and application of the exclusions and limitations and other provisions of the policy at the time the services are rendered.
Include the "Date of Current Illness" on the CMS-1500 and the "Occurrence Code and Date" on the UB-04 when submitting claims.
Blue Cross and Blue Shield of Oklahoma (BCBSOK) requests that you routinely include the "Date of Current Illness" or "Occurrence Code" and the associated date in your claim submissions. This will help eliminate the need to contact Customer Service when a claim denies unexpectedly needing this information.
When submitting the CMS-1500, the "Date of Current Illness" (also known as the "on-set date") is entered into Box 14 to indicate the date of the first symptom/illness, accident/injury, or last menstrual period (LMP) for pregnancy. The first date, if the patient has had the same or similar illness, is entered into Box 15.
When submitting the UB-04, the "Occurrence Code" and associated date is entered in fields 31-36 and defines a significant event related to the claim. The most commonly recognized "occurrence codes" by BCBSOK are listed below:
|04||Accident – Employment Related|
|10||Last Menstrual Period (LMP)|
|11||Onset of Symptom/Illness|
|33||First Day of Medicare Coordination Period for End Stage Renal Disease (ESRD)|
Remember that the first date of service is not always the on-set/occurrence date. Claims may process differently, depending what date is entered. Be sure that you are entering the actual date on all claims.
For Federal Employee Program members, a predetermination can be requested for outpatient services. This will assist in determining medical necessity prior to original submission. The predetermination form is found on our website under Provider forms. View a listing of codes that require a review or are non-covered.
For BlueLincs HMO members, a precertification can be requested prior to services being rendered in an outpatient setting. These will be reviewed for medical necessity retrospectively if a precertification is not obtained. The predetermination form is found on our website under Provider forms. View a listing of codes that require a review or are non-covered.
For fully-insured memberships and self funded groups, a predetermination can be requested for outpatient procedures. Please make sure to include any pertinent information in order for our medical review staff to verify medical necessity. If a predetermination is not completed prior to services being rendered, a medical necessity review will be required before benefits can be determined. The predetermination form is found on our website under Provider forms. View a listing of codes that require a review or are non-covered.
For out of state memberships (BlueCard), contact the home plan directly to verify benefits and precertification requirements. This information can be accessed through Availity under "Eligibility and Benefits."