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ClaimsXtenTM Third Quarter 2014 Updates

July 2, 2014

Updated Aug. 6, 2014

Blue Cross and Blue Shield of Oklahoma (BCBSOK) 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. BCBSOK will normally load this additional data to the BCBSOK claim processing system within 60 to 90 days after receipt from McKesson and will confirm the effective date on the BCBSOK 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 BCBSOK Provider website.

Beginning on or after Sept. 29, 2014, BCBSOK 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 9
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

 

The ClaimsXten tool offers flexible, rules-based claims management with the capability of creating customized rules, as well as the ability to read historical claims data. ClaimsXten can automate claim review, code auditing and payment administration, which we believe results in improved performance of overall claims management.

To help determine how coding combinations on a particular claim may be evaluated during the claim adjudication process, you may continue to utilize Clear Claim Connection™ (C3). C3 is a free, online reference tool that mirrors the logic behind BCBSOK's code-auditing software. Refer to our website at bcbsok.com/provider for additional information on gaining access to C3.

For updates on ClaimsXten, watch the News and Updates on our Provider website, as well as upcoming issues of the Blue Review.


Checks of eligibility and/or benefit information are not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member's eligibility and the terms of the member's certificate of coverage applicable on the date services were rendered.

ClaimsXten and Clear Claim Connection are trademarks 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.