Blue SMEssentials Blue Advantage HMO And Blue PremierSM .

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Blue EssentialsSM, Blue Advantage HMOSMand Blue PremierSM Provider Manual Filing ClaimsTHIS SECTION CONTAINS A REQUIRED DISCLOSURE CONCERNINGCLAIMS PROCESSING PROCEDURESPlease NoteThroughout this provider manual there will be instances when there arereferences unique to Blue Essentials, Blue Advantage HMO and BluePremier. These product specific requirements will be noted with theproduct nameThe following topics are covered in this section:In thisSectionTopicPageBehavioral Health NoteF–6Claims Processing QuestionsF–7Claims Submission – Timely Filing ProceduresF–7Blue Advantage HMO Only Grace PeriodF-8Blue Essentials Only Grace PeriodF–8Changes Affecting Your Provider Record ID - NPI Number,Name Change, Change in Your Address, etcF–9Prompt PayF – 10Prompt Pay Legislation - PenaltyF – 10Prompt Pay Legislation - Definition of Clean ClaimF – 11Prompt Pay Legislation -Statutory Claim Payment PeriodsF – 12Prompt Pay Legislation -Statutory Penalty AmountsF – 12Coordination of Benefits and Patient’s ShareF – 13Prompt Pay Legislation -Coordination of BenefitsF – 14Coordination of Benefits/SubrogationF – 15Correct CodingF – 15Splitting Charges on ClaimsF – 15Services Rendered by Physician, Professional Provider,Facility, or Ancillary ProviderF – 16Billing for Non-Covered ServicesF – 17Surgical Procedures Performed in the Physician’s orProfessional Provider’s OfficeF - 18Contracted Physicians. Professional Providers, Facility andAncillary Providers Must File ClaimsF - 18CPT Modifier 50 Bilateral Procedures–Professional Claims OnlyF - 19Proper Speech Therapy BillingF - 20Updated 04-12-2018Page F - 1A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

Blue Essentials, Blue Advantage HMO and BluePremier Provider Manual - Filing ClaimsPlease NoteThroughout this provider manual there will be instances when there arereferences unique to Blue Essentials, Blue Advantage HMO and BluePremier. These product specific requirements will be noted with theproduct nameThe following topics are covered in this section:In thisTopicSection,Cont’dPageSubmission of CPT 99000 With Modifier 59F – 20Care Coordination ServicesF – 21Urgent Care Center Services Billed Using CPT Code S9088F – 21Billing and Documentation Information and Requirements Permissible BillingF – 22F – 22F – 22F – 23F – 23F – 23F – 23 Pass through BillingUnder Arrangement BillingAll Inclusive BillingOther Requirements and Monitoring CLIA Certification Requirement Review of CodesLimitations and ConditionsObligation to Notify BCBSTX of Certain ChangesAssignmentFraudulent BillingFiling Claims RemindersPaperless Claim Processing OverviewF – 23F – 24F – 24F – 24F – 24F – 25The Availity Health Information Network (Availity,L.L.C.)F – 26F – 26Electronic Remittance Advice (ERA)F – 26Electronic Funds Transfer (EFT)F - 27Electronic Payment Summary (EPS)F - 27Electronic Claim Submission & Response ReportsF – 27Payer Response ReportsF - 28System ImplicationsF – 28What are the Benefits of EMC/EDI?F – 29Payer Identification CodeF – 29What Claims Can Be Filed Electronically?iExchange Confirmation NumberF – 30F – 30How does Electronic Claim Filing Work?F - 31Submit Secondary Claims ElectronicallyF – 31Duplicate Claims Filing is CostlySubmit Encounter Data ElectronicallyF – 31F – 32Providers with Multiple SpecialtiesF – 34Updated 04-12-2018A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield AssociationPage F-2

Blue Essentials, Blue Advantage HMO and Blue PremierProvider Manual - Filing ClaimsPlease NoteIn thisSectionThroughout this provider manual there will be instances when thereare references unique to Blue Essentials, Blue Advantage HMOand Blue Premier. These product specific requirements will benoted with the product name.The following topics are covered in this section:TopicPageAddresses for Claims Filing and Customer Service Phone NumbersF – 35CMS-1500 (02/12) Claim Form IntroductionF – 36Ordering Paper Claim FormsRequired Elements for Clean ClaimsF – 36F – 36Return of Paper Claims with Missing Billing Provider IdentificationNumberSample CMS-1500 (02/12) Claim FormF – 38CMS-1500 (02/12) claim Form Instructions (Key)F – 39CMS-1500 (02/12) Place of Service Codes, Instructions & Examplesof Supplemental Information in Item Number 24 and RemindersF – 40Filing CMS-1500 Claims for Ancillary FacilitiesF – 41Durable Medical EquipmentF – 42DME BenefitsF – 42F – 42Custom DMERepair of DMEReplacement PartsDME Rental or PurchaseDME PreauthorizationPrescription or Certificate of Medical NecessityF – 37F – 43F – 43F – 43F – 43Life-Sustaining DMEF – 44F – 45Home Infusion Therapy (HIT)F – 48Services Incidental to Home Infusion and Injection TherapyPer DiemF – 50Home Infusion Therapy ScheduleF – 51eviCoreImaging CentersF – 64F – 64Imaging Center Tests Not Typically CoveredF – 65Independent Laboratory Claims FilingF – 66Independent Laboratory Preferred ProviderF – 66Independent Laboratory PolicyF – 67Updated 04-12-2018Page F - 3A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

Blue Essentials, Blue Advantage HMO and Blue PremierProvider Manual - Filing ClaimsPlease NoteThroughout this provider manual there will be instances when there arereferences unique to Blue Essentials, Blue Advantage HMO and BluePremier. These product specific requirements will be noted with theproduct nameThe following topics are covered in this section:In thisTopicPageSection,Independent Laboratory – Non Covered TestsF – 68cont’dProsthetics & OrthoticsF – 68Prosthetics & Orthotics – Non CoveredF – 69Radiation Therapy Center Claims FilingHow to Complete the UB-04 Claim FormF – 75F – 76What Forms are AcceptedF – 76Sample UB-04 FormF – 77Procedure for Completing UB-04 Form (Key)F – 78Hospital Claims – Filing Instructions - OutpatientF – 83Revenue Code and CPT/HCPCS CodesF – 86Hospital Claims – Filing Instructions - InpatientF – 87F – 87Type of Bill (TOB)NPIF – 87Patient StatusF – 87Occurrence Code/DateF – 87Late Charges/CorrectedF – 87DRG FacilitiesF – 88Preadmission TestingF – 88F – 88Pre-Op TestsMother & Baby ClaimsClinic ChargesDiabetic EducationTraumaProvider Based BillingTreatment Room ClaimDRG Carve Outs Prior to Grouper -25DRG Carve Outs for Grouper 25, 26, and 27DRG Carve Outs for Grouper 28DRG Carve Outs for Grouper 29F – 88F – 89F – 89F – 89F – 90F – 94F – 96F – 97F – 98F – 99Updated 04-12-2018A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield AssociationPage F - 4

Blue Essentials, Blue Advantage HMO and Blue PremierProvider Manual - Filing ClaimsPlease NoteThroughout this provider manual there will be instances when there arereferences unique to Blue Essentials, Blue Advantage HMO and BluePremier. These product specific requirements will be noted with theproduct nameIn thisSectionThe following topics are covered in this section:TopicPageDRG Carve Outs for Grouper 30F – 100Cardiac Cath/PTCA – NONOPPSPTCA/Cardiac Cath – NONOPPSAmbulatory Surgery Centers/Outpatient Claims FilingF – 101F – 109F – 112Freestanding Cardiac Cath CentersCardiac Cath Lab ProceduresF – 113Freestanding Cath Lab CenterF – 122Dialysis Claim FilingF – 127Freestanding Emergency Centers (FEC) ClaimsF – 127Home Health Care Claim FilingF – 128Non-Skilled Service Examples for Home Health CareF – 129Hospice Claim FilingRadiation Therapy Center Claim FilingSkilled Nursing Facility Claim FilingF – 130F – 130Rehab Hospital Claim FilingF – 131Blue Essentials Only – Submit Encounter Data ElectronicallyClaim Review ProcessF – 132F – 133Proof of Timely FilingClaim Reviews, Dispute Types & Timeframes for RequestsClaim Review FormRecoupment ProcessSample PCS RecoupmentProfessional Claim Summary Field ExplanationsRefund PolicyRefund LettersProvider Refund Form (Sample)Provider Refund Form InstructionsElectronic Refund Management (eRM)How to Gain Access to eRM Availity UsersF - 133Updated 04-12-2018F – 113F – 131F – 134F – 135F – 136F – 138F – 139F – 140F – 143F – 144F – 145F – 146F – 146Page F - 5A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

Blue Essentials, Blue Advantage HMO and Blue PremierProvider Manual - Filing ClaimsPlease NoteBehavioralHealthNoteThroughout this provider manual there will be instances when thereare references unique to Blue Essentials, Blue Advantage HMOand Blue Premier. These product specific requirements will benoted with the product nameFor information about behavioral health claims filing, refer tothe “Behavioral Health” Section in the Provider ManualUpdated 04-12-2018A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield AssociationPage F - 6

Blue Essentials, Blue Advantage HMO and Blue PremierProvider Manual - Filing ClaimsPlease NoteClaimsProcessingQuestionsThroughout this provider manual there will be instances when thereare references unique to Blue Essentials, Blue Advantage HMOand Blue Premier. These product specific requirements will benoted with the product nameShould you have a question about claims processing, as the firstpoint of contact, call your electronic connectivity vendor, i.e., Availityor other electronic connectivity vendor of your choice or contact BlueEssentials, Blue Advantage HMO or Blue Premier ProviderCustomer Service:Blue Essentials – 877-299-2377Blue Advantage HMO – 800-451-0287Blue Premier – eduresBlue Essentials, Blue Advantage HMO and Blue Premier claimsmust be submitted within 180 days of the date of service. BlueEssentials, Blue Advantage HMO and Blue Premier physicians,professional providers, facility and ancillary providers must submit acomplete claim for any services provided to a member. Claims that arenot submitted within 180 days from the date of service are not eligiblefor reimbursement. Claims submitted after the designated cut-off datewill be denied on a Provider Claim Summary (PCS).The member cannot be billed for these denied services. BlueEssentials, Blue Advantage HMO. and Blue Premier physicians,professional providers, facility and ancillary providers may not seekpayment from the member.Please ensure that statements are not sent to Blue Essentials, BlueAdvantage HMO and Blue Premier members, in accordance with theprovisions of your Blue Essentials, Blue Advantage HMO and BluePremier contract.If a Blue Essentials, Blue Advantage HMO and Blue Premierphysician, professional provider, facility or ancillary provider feels that aclaim has been denied in error for untimely submission, the BlueEssentials, Blue Advantage HMO and Blue Premier physician,professional provider, facility or ancillary provider may submit a claimreview request. The Claim Review Form and instructions are locatedfurther within this manual.If a claim is returned to the Blue Essentials, Blue Advantage HMOand Blue Premier provider for additional information, it should beresubmitted to Blue Essentials, Blue Advantage HMO and BluePremier within 180 days. The 180 days begin with the date BlueEssentials, Blue Advantage HMO and Blue Premier mails therequest. If claims are filed electronically, then Blue Essentials, BlueAdvantage HMO and Blue Premier physicians or professional providersmust make the necessary corrections and refile the claim electronicallyin order for the claim to be processed.Updated 04-12-2018Page F - 7A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

Blue Essentials Blue Advantage HMO and Blue PremierProvider Manual - Filing ClaimsPlease NoteThroughout this provider manual there will be instances when thereare references unique to Blue Essentials, Blue Advantage HMOand Blue Premier. These product specific requirements will benoted with the product name.BlueAdvantageHMO OnlyGrace PeriodThe Affordable Care Act (ACA) includes a provision that givesHealth Insurance Marketplace members who receive advancedpremium tax credits (APTC) also known as subsidies, a threemonth grace period to pay their premiumACA Grace Period Impacts: TexasACA Grace Period TimelineNonpayment ofPremiumACA Grace Period:Month 1 Member enters intothe ACA Grace Period. BCBSTX will adjudicateclaims for dates ofservice rendered withinthe first month. No impact to membereligibility. No impact to medicalservices. HMO serviceswill be authorized.ACA Grace Period:Months 2 and 3Post ACA GracePeriod: Month 4 Member is in the ACAGrace Period. Member’s policyterminated withBCBSTX retroactive today 1 of month 2. BCBSTX willadjudicate claims forservice the memberreceives duringmonths 2 and 3. BCBSTX will recoverany claims paid inmonths 2 and 3 fromthe provider. Providers are notifiedthat member is in agrace period whenthey check eligibilityand benefits for theirpatient. HMO servicesauthorized.18BlueEssentialsOnly GracePeriodStandard 30 day grace period will apply for enrollees.Updated 04-12-2018A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield AssociationPage F - 8

Blue Essentials Blue Advantage HMO and Blue PremierProvider Manual - Filing ClaimsPlease NoteThroughout this provider manual there will be instances when thereare references unique to Blue Essentials, Blue Advantage HMOand Blue Premier. These product specific requirements will be notedwith the product name.ChangesAffectingYourProviderRecord ID NPI NumberChange,NameChange,Change inAddress, etcReport changes immediately – to your name, telephone number,address, NPI number(s), specialty type or group practice, etc.1)To submit changes directly to BCBSTX by email, goto bcbstx.com/provider and click on the Network Participationtab, then scroll down to – Update Your Information – andcomplete/submit the Demographic Change Form, or2)by calling Provider Administration at 972-996-9610, press 3, or3)by contacting your Network Management Office. For moredetailed information, refer to Section A - Support Services inthe Blue Essentials, Blue Advantage HMO and Blue PremierProvider Manual.Keeping BCBSTX informed of any changes you make allows forappropriate claims processing, as well as maintaining the BlueEssentials and Blue Advantage HMO Provider Directory with currentand accurate information.Updated 04-12-2018Page F - 9A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

Blue Essentials, Blue Advantage HMO and Blue PremierProvider Manual - Filing ClaimsPlease NoteThroughout this provider manual there will be instances when thereare references unique to Blue Essentials, Blue Advantage HMOand Blue Premier. These product specific requirements will benoted with the product name.Prompt PayBlue Essentials, Blue Advantage HMO and Blue Premier complywith the Texas Prompt Pay Act. The Prompt Pay Act requiresinsurance carriers to pay clean claims that are subject to the Act’srequirements within certain specified statutory payment periods.Insurance carriers that do not comply with Prompt Pay Act’sstandards may owe statutory penalties to the provider.Prompt PayLegislation- PenaltyProviders are eligible for statutory prompt pay penalties under theTexas Prompt Pay Act only when certain requirements are met,including: Claim is made for subscriber of plan that is fully insured by BCBSTX The patient’s insurance plan is regulated by the Texas Departmentof Insurance (TDI); The claim is submitted to Blue Essentials, Blue Advantage HMOand Blue Premier as a clean claim; The provider files the claim by the statutory filing deadline; The provider is a contracting preferred provider, and The services billed on the claim are payable.Blue Essentials, Blue Advantage HMO and Blue Premier proactivelymonitors the timeliness of its payments for eligible claims and issuespenalties to providers when it determines penalties are owed. If youbelieve statutory penalties are due and have not received a penaltypayment from Blue Essentials, Blue Advantage HMO and BluePremier, you may request review of penalty eligibility by contactingBlue Essentials, Blue Advantage HMO and Blue Premier ProviderCustomer Service at 800-451-0287.Updated 04-12-2018Page F—10A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

Blue Essentials, Blue Advantage HMO and Blue PremierProvider Manual - Filing ClaimsPlease NoteThroughout this provider manual there will be instances when thereare references unique to Blue Essentials, Blue Advantage HMOand Blue Premier. These product specific requirements will be notedwith the product name.Prompt PayLegislation Definition ofa Clean ClaimIn order to be eligible for Prompt Pay penalties, providers must submit aclean claim. A clean claim includes all the data elements specified by the TDIin prompt pay rules or applicable electronic standards. Each specified dataelement must be legible, accurate, and complete.For non-electronic submissions by institutional providers, a claim should besubmitted using the Centers for Medicare and Medicaid Services (CMS) FormUB-04.1 The UB-04 claim form must include all the required data elements setforth in TDI rules,2 including, if applicable, the amount paid by the primaryplan.3For non- electronic submissions by professional providers, a claim shall besubmitted on a CMS Form 1500(02/12) claim form.Electronic claims by professional or institutional providers must be submittedusing the ASC X12N 837 format in order to be considered a clean claim.Providers must submit the claim in compliance with the Federal HealthInsurance Portability and Accountability Act (HIPAA) requirements related toelectronic health care claims, including applicable implementation guidelines,companion guides, and trading partner agreements.4A claim that does not comply with the applicable standard is a deficientclaim and will not be penalty eligible.5 When Blue Essentials, BlueAdvantage HMO and Blue Premier are unable to process a deficientclaim, it will notify the provider of the deficiency and request the correctdata element.At times, deficient claims contain sufficient information for BCBSTX’sadjudication and payment. Rather than requiring the provider to correct thedeficiency before payment is issued, BCBSTX considers it in the best interestof providers to pay deficient claims as soon as possible. However, becausedeficient claims are not clean claims, they are not eligible for penalties even ifBCBSTX pays the claim outside of the applicable payment period.61 Ex. C, Tex. Ins. Code § 1301.131(b).2 Ex. B, 28 Tex. Admin. Code § 21.2803(b)(3).3 Ex, B, 28 Tex. Admin. Code § 21.2803(d)(1).4 Ex. B, 28 Tex. Admin. Code § 21.2803(e)5 Ex. D, 28 Tex. Admin. Code § 21.2802(10)6 Ex. E, Report on the Activities of the Technical Advisory Committee on Claims Processing(Sep. 2004), at pp. 6-7.Updated 04-12-2018Page F—11A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

Blue Essentials, Blue Advantage HMO and Blue PremierProvider Manual - Filing ClaimsPlease NotePrompt PayLegislation StatutoryClaimPaymentPeriodsPrompt PayLegislation .Ex.Ex.Ex.Throughout this provider manual there will be instances when thereare references unique to Blue Essentials, Blue Advantage HMOand Blue Premier. These product specific requirements will benoted with the product name.When a contracting provider su

Blue Essentials, Blue Advantage HMO and Blue Premier claims must be submitted within 180 days of the date of service. Blue Essentials, Blue Advantage HMO and Blue Premier physicians, professional providers, facility and ancillary providers must submit a complete claim for any services provided to a member. Claims that are

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