2009 Provider News and Updates

Availity Health Information Network Maintenance

The Availity Health Information Network will be unavailable due to scheduled system maintenance beginning Saturday, December 5, 2009, at 4 p.m. (CST) until Sunday, December 6, at 11 a.m. We apologize for any inconvenience.

Public Web Site Redesign

Newly Designed Public Web Site Launched

New public tools and resources focus on guidance and support

More than ever, it is important for your patients to understand their health insurance. Our Web site redesign, launched in mid-December, focuses on providing this guidance and support.

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New Administration of Maternity Program

Beginning in late November 2009, the Blue Cross and Blue Shield of Oklahoma (BCBSOK) Special Beginnings® maternity program will be managed internally by program staff in our Health Care Management Division instead of through the independent contractor Alere that had previously managed the program.

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Billing Dispute External Review Process (BDERP)

Effective November 21, 2009, Medical Doctors/Doctors of Osteoparth (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 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 an the applicable fees can be found on MES Solutions' Web site.

Thomas-Love Settlement Provision 7.8(d) — Significant Edits

The following significant edits are posted in compliance with the Thomas-Love Settlement:

The significant edits posted on Jan. 9, 2009 are also available for view.

Provider Claim Summaries to Be Generated on All Adjustments

Currently, when a claim is adjusted and no additional payment is made, a Provider Claim Summary (PCS) is not generated. We are pleased to report that, beginning in November, a PCS will now be issued in all instances when a claim is adjusted.

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Paper to Electronic (PCS to EPS) Transition Reminders

If your office is enrolled for the Electronic Remittance Advice (ERA), you are automatically enrolled to receive the Electronic Payment Summary (EPS). The EPS contains the same information as your paper Provider Claim Summary (PCS); however, the EPS arrives faster and offers easier archiving and retrieval capability.

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Code Auditing Upgrade and Modifier 59 Exempt Auditing

Blue Cross and Blue Shield of Oklahoma (BCBSOK) hereby gives notice that changes will be made to the claims processing system that affects our bundling logic. We will be upgrading to McKesson ClaimCheck Version 43 effective on or after January 19, 2010 for all lines of business. Due to our licensing agreement with McKesson, mass lists or spreadsheets of bundling combinations cannot be distributed.

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H1N1 Information for Providers

With the impending delivery of the new vaccine for the novel A H1N1 flu virus, Blue Cross and Blue Shield of Oklahoma (BCBSOK) wants to make our network physicians aware of our policy concerning coverage of charges for administering the vaccine for BCBSOK members.

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EDI Update

Please be advised that effective October 19, 2009 our 835 (ERA) files will no longer contain the Payee Additional Identification (REF*PQ) segment. This segment is located at the Header Level, Loop 1000B.

Availity's New Claim Research Tool Now Available

Availity's new online Claim Research Tool (CRT) provides your office staff greater claims accuracy and increased office efficiency in managing your account receivables. The CRT gives your staff fast, real-time access to enhanced Blue Cross and Blue Shield of Oklahoma claim status information, with features that include:

  • Status of multiple claims in one view
  • Member ID and claim (DCN) number look-ups
  • Patient account and group number information
  • Detailed line-level information including reason codes and descriptions
  • Related copay, deductible, and coinsurance amounts

The CRT also ends the need for costly, time-consuming phone calls. The tip sheet  makes using this great new tool a breeze. Best of all, CRT delivers all of the above at no cost to you!

Availity is a registered trademark of Availity, L.L.C., an independent, third party vendor.

Prior Authorization / Concurrent Review

Blue Cross and Blue Shield of Oklahoma (BCBSOK) requires prior authorization for all inpatient admissions for all lines of business. If the admitting physician obtained prior authorization for a planned inpatient admission, BCBSOK does not need concurrent review if the patient is discharged within the pre-approved length of stay.

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Facility Address Reminder

If you are a facility that files claims on a UB-04 claim form, please remember to follow the guidelines listed in the current UB-04 Editor .

When you have a different billing and physical address, please use Box 1 to list your physical address and Box 2 to list your billing address. This helps to expedite claims processing and ensure there is no confusion as to where the services were rendered.

This user guide will also assist you with identifying the fields that are required to be completed per our claims processing guidelines and help to eliminate unnecessary claim delays.

Learn How to File Unlisted Procedure Codes (NDCs) Electronically

Are you interested in filing your unlisted procedure codes for drugs and injections electronically, but unsure how? Providers often file unlisted procedure codes on paper claims in order to include the descriptions of the services rendered. The electronic format system for filing claims includes a descriptive field for each line of service, allowing providers to include the description of services rendered. This helps reduce the unnecessary filing of paper claims.

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Claims and Correspondence Address Reminder

In an effort to provide our customers with timely and accurate claims processing service, please remember to submit all claims and correspondence to the following P. O. Box address:

BlueCross BlueShield of Oklahoma
P.O. Box 3283
Tulsa, OK 74102-3283

This address is the same for all lines of business and will allow us to better serve you in a timely manner.

If any other documentation other than the original claim submission is being sent to the above address, please remember to attach the Provider Claim Appeal/Reconsideration Review Request Form located on our Web site.

Taxonomy Codes

Taxonomy codes are administrative codes set for identifying the provider type and area of specialization for health care providers. Each taxonomy code is a unique ten character alphanumeric code that enables providers to identify their specialty at the claim level. Taxonomy codes are assigned at both the individual provider and organizational provider level.

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