Blue Cross and Blue Shield of Louisiana Institutional 837I ... · Blue Cross and Blue Shield of Louisiana Institutional 837I Electronic Business Rules Guide April 13, 2011 3 I. Introduction

Blue Cross and Blue Shield of Louisiana

Institutional 837I

Electronic

Business Rules Guide

Blue Cross and Blue Shield of Louisiana Institutional 837I Electronic Business Rules Guide

April 13, 2011 2

Table of Contents

I. Introduction of Guide ........................................................................................... 3 II. General Information ............................................................................................. 4

Hours of Operation ...................................................................................... 4 Customer Support ....................................................................................... 4 Processing Cycle ......................................................................................... 4

III. Validation of Blue Cross Contract Numbers .................................................... 5 IV. Institutional Claims Business Rules ................................................................ 7 V. Special Billing Requirements ........................................................................... 31

Home Health Claims ................................................................................. 31 Maternity Claims ........................................................................................ 32 Mother and Baby Discharged on the Same Date ..................................... 32 Mother and Baby Discharged on Different Dates ..................................... 32

Present on Admission Indicators………………………………………… 33 VI. Reports Generated from Clearinghouse ........................................................ 34

Communication Reports ............................................................................. 35 Functional Acknowledgment Reports ........................................................ 37 Claims Submission Validation Reports ...................................................... 40

VII. 835 Remit Process ........................................................................................... 46 VIII. UB04 -Type of Bill for Facets System ........................................................... 47 IX. Not Accepted Error Definitions ....................................................................... 48

Not Accepted Error Codes .......................................................................... 49 NPI Edits……………………………………………………………………… 75


April 13, 2011 3

I. Introduction of Guide This document complements the HIPAA 837 Implementation Guide for Institutional Claims (004010X096) and is designed to be used in conjunction with the Blue Cross and Blue Shield of Louisiana (BCBSLA) Institutional Claims Companion Guide. This document is for informational purposes only and is not intended to replace the Implementation Guide. The information provided here offers specific details on BCBSLA institutional claims completion. The detailed criteria can be useful in developing validation edits for BCBSLA claims. Once a claim reaches the BCBSLA processing system, more extensive editing is performed. If a transaction does not meet the minimum specifications outlined in this guide, then BCBSLA may not be able to process those transactions. Claims that do not pass the stated criteria are subject to rejection, deletion, or a delay in processing. Additionally, claims must conform to the provisions set forth in the provider network contracts. This is a general guide developed for the electronic submission of all institutional claims. Please be aware that some of the instructions described within this handbook may not apply to your facility. Specialized services such as home health, hospice, and maternity-related claims are referenced in separate sections. If you have questions about this guide, please contact BCBSLA EDI Services. Phone: 225.291-4EDI (4334) Email address: [email protected]

Mailing Address: EDI Customer Operations

Attention: Clearinghouse Services Blue Cross and Blue Shield of Louisiana P.O. Box 98029 Baton Rouge, LA 70898-9029


April 13, 2011 4

II. General Information

Hours of Operation The system will be available 24 hours, 7 days a week. The system will be periodically unavailable for scheduled maintenance and updates outside of normal business hours only. Though BCBSLA strives to have the systems available 24 hours, 7 days a week, uninterrupted service is not guaranteed.

Customer Support

Customer support will be provided during our normal business hours: Monday – Friday*, 8:00 a.m. to 4:30 p.m. Central Standard Time (CST) *Except holidays Telephone Support 225-291-4EDI (4334)

Email Address: [email protected]

Mailing Address: EDI Customer Operations Attention: Clearinghouse Services Blue Cross and Blue Shield of Louisiana P.O. Box 98029

Baton Rouge, LA 70898-9029 Processing Cycle

BCBSLA will accept an unlimited number of transmissions within an operating day; however, batch transactions will be accumulated and processed once a day.

Batch Transactions: Batch transmissions are moved at 3 p.m. (CST) for nightly processing. All batch transmissions received after this time will be processed the following business day.

Real-Time Transactions: Real-time transactions will be processed while the Trading Partner is connected.


April 13, 2011 5

III. Validation of Blue Cross Contract Numbers Alpha prefixes Blue Cross and Blue Shield plans assign an individual contract number to each subscriber. The contract number uniquely identifies the specific contract.

Most contract numbers are preceded by a 3-position alpha prefix. The alpha prefix identifies the Plan or national account to which the member belongs. The alpha prefix is the key element used to identify and correctly route electronic or hard copy claims to the appropriate processing area or Blue Cross plan.

See the example of a BCBSLA ID card below. The member number and alpha prefix are circled.


April 13, 2011 6

Identifying Contracts BCBSLA currently processes claims through our central operating system Legacy, as well as our new updated claims system called Facets. Eventually, all lines of business will be moved to the new Facets system. The information below differentiates the contract numbers within the Legacy and Facets systems. Legacy Blue Cross and Blue Shield of Louisiana (BCBSLA) contracts:

• Begin with alpha prefix “XU?” • Followed by 8 to 10 positions • If the contract has 8 positions, the 7th position can be numeric or alpha

(if alpha will be A, B, N, V or X) last position will be 1. • If the contract number has 9 positions the 10th position will be 1-9 or C. • Example: XUA 1234567891 or XUB 123456A1

Facets

• Begins with alpha prefix “XU” • Contract number begins with a 200 behind the alpha prefix

Out-of-area and National account prefixes

• Begin with any alpha prefix other than XU • Can be any length of characters • Example: MBN 123456789

Federal Employees Contracts (FEP)

• FEP contracts do not have an alpha prefix • The first position of the contract number must be an 'R', the second

thru ninth will be numeric and the tenth position, if present, will be zero (0).


IV. Institutional Claims Business Rules BCBSLA will accept all valid 837 transactions, but the table below depicts the data elements that will facilitate prompt and accurate claims processing for BCBSLA institutional claims.

April 13, 2011 7

UB04 Form

Locator

Field Name

192 NSF Reference

837I Reference and Page No.

Notes

1

Provider Name Address Phone

Record 10 Field 12 Record 10 Field 13 -16 NA

2010AA / NM103

p 77

2010AA /| N301, p 79

N401 p 80 N402 p 81 N403 p 81

NA

Must be the name of the provider who rendered services. Must be the address, city, state, and ZIP of the provider who rendered services.

2 N/A

3 Patient Control Number

Record 20 Field 3

2300 / CLM01 p 158

Must be the number or code that is used by your facility to retrieve or post records. A maximum of 20 positions will be stored and returned by BCBSLA on the 835 ERA. A maximum of 15 positions will be returned on the paper payment register.

4 Type Bill

This is a three-position code that indicates the type of facility, the bill classification and the frequency.


UB04 Form

Locator

Field Name

192 NSFReference

837I Reference Notesand Page No.

Position 1-2 Position 3

Record 40 Field 4 Position 1-2 Record 40 Field 4 Position 3

2300 / CLM05 -1 p 159

2300 / CLM05 -3 p 160

For inpatient and outpatient claims, choose one digit from each category below:

First Digit – Type of Facility 1 = Hospital (inpatient or outpatient) 2 = Skilled Nursing Facility 3 = Home Health 8 = Special Facility - Hospital (outpatient) Second Digit – Bill Classification (Other than Special Facilities) 1 = Hospital 3 = Outpatient 4 = Other (outpatient)

Second Digit – (Special Facilities Only) 1 = Hospice (non-hospital based) 2 = Hospice (hospital based) 3 = Ambulatory Surgery Center

Third Digit – Frequency 1 = Full Billing 2 = Interim Bill (first claim)* 3 = Interim Bill (continuing claim)* 4 = Interim (final discharge claim)* 5 = Late-charges-only claim 7= Replacement of prior claims 8 =Void/Cancel of prior claim

*Member providers cannot submit interim billings for inpatient services. If 3rd position is 2 or 3 (Interim), the discharge status must equal 30.

April 13, 2011 8


UB04 Form

Locator

Field Name

192 NSFReference


April 13, 2011 9

If 3rd position is 1 or 4, discharge status field cannot equal 30.

5 Fed Tax No. Record 10 Field 4, 5

2010AA / NM109p 78

Must be the federal tax identification number for the facility where the services were rendered.

6 Statement covers Period From-Through

Record 20 Field 19, 20

2300 / DTP03 p 168

Must be the beginning and ending date of the period covered by this bill. The FROM date must be a valid date on or prior to the current date. The THROUGH date must be a valid date equal to or after the Covered From Date.

7 Covered Days

Record 30 Field 20

2300 / QTY01 & 02 /CA p 306

For inpatient claims only. Must be the total number of covered days. • The number of covered days must equal the

sum of all units indicated for the accommodation revenue codes 110 - 219

For maternity claims where newborn charges are combined with mother’s bill, covered days must not include units for nursery accommodation. (nursery accommodation will be revenue 17X) If the discharge status is 30 (type bill 112 or 113),


UB04 Form

Locator

Field Name

192 NSFReference


then the sum of covered days indicated for accommodation revenue codes must be equal to the covered thru date minus the covered from date plus 1. Example 010102 thru 010902 units would be 9 days.

8 Non-covered Days

Record 30 Field 21

2300 / QTY01 & 02 / NA p 307

The non-covered day’s field must be used when revenue code 180 – 189 (Leave of Absence) is present and must be equal to the units indicated for revenue codes 180 - 189. This field is not required for outpatient claims.

9 Coinsurance

Days Not used by BCBSLA

10 Lifetime Reserve Days

Not used by BCBSLA

11 NA NA

12 Patient Name Record 20 Field 4, 5, 6

2010BA / NM103, 104, 105

p 109

2010CA / NM103, 104, 105

p 146

Must be the patient’s last and first name. Middle initial can be reported, if available. Do not use titles or nicknames. When filing for a newborn, the infant’s given name must be used. Patient’s first name cannot be BABY, BABYBOY, BABYBOY1, BABYBOY2, BABYBOY2, BABYBOY3, BABYBOY4, BABYGIRL,

April 13, 2011 10


UB04 Form

Locator

Field Name

192 NSFReference


BABYGIRL1, BABYGIRL2, BABYGIRL3, BABYGIRL4, BABY1, BABY2, BABY3, BABY4, GIRL, BOY, BOY1, BOY2, BOY3, BOY4, GIRL1, GIRL2, GIRL3, GIRL4, INFANT, TWIN, NEWBORN, NEWBO, INFANT1, INFANT2, INFANT3, INFANT4, BABY BOY1, BABY BOY2, BABY BOY3, BABY BOY4, BABY GIRL1, BABY GIRL2, BABY GIRL3, BABY GIRL4, BAB1, BAB2, BAB3, BAB4, UNKNOWN, or TRIPLET.

13 Patient Address

Record 20 Field 12, 13, 14, 15, 16

2010BA / N301 & N302

N401, N402, N403 P 112

2010CA / N301, N302, p 148 N401, N402, N403, p 149

Must be the patient’s address, city, state and ZIP.

14 Patient Birth date

Record 20 Field 8

2010BA / DMG02 p 116

2010CA / DMG02 p 152

Must be the patient’s date of birth. Must be a valid date on or before the “Covered From Date”

April 13, 2011 11


April 13, 2011 12

UB04 Form

Locator

Field Name

192 NSF Reference


Notes

15 Sex Record 20 Field 7

2010BA / DMG03 p 116

2010Ca / DMG03 p 152

Must be the code indicating the patient’s sex. F, M and U are valid codes, however in order for BCBSLA to complete processing; F or M must be reported.

16 Marital Status

N/A

17 Admission Date

Record 20: Field 17

2300 / DTP03 p 170

Must be completed only on inpatient claims. Must be the date the patient was admitted to the facility. Must be a valid date on or prior to the current date. If second and third positions of the type bill are “11” or “12”, then the Admission Date must be equal to the Covered From Date.

18 Admission Hour

Record 20: Field 18

2300 / DTP03 p 170

Must be reported on all inpatient claims. 837I format requires 4 position hour and minute of admission (hhmm).

19 Admission Type

Record 20: Field 10

2300 / CL101 p 171

Required on inpatient claims.

20 Source of Admission

Record 20: Field 11

2300 / CL102 p 172

Required on inpatient claims.


UB04 Form

Locator

Field Name

192 NSFReference


April 13, 2011 13

When admission type equals 4 (Newborn), then source of admission codes that apply to newborns must be used. (1 thru 4.)

21 Discharge

Hour Record 20: Field 22

2300 / DTP01 / 096 p 165

2300 / DTP03 / p 166

Required on inpatient claims with the 3rd position of bill type equal to 1 or 4.

22 Patient Status

Record 20: Field 21

2300 / CL103 p 172

Required for all inpatient claims. If ‘Discharge Status’ is 30, the 3rd position of ‘Type Bill’ must be 2 or 3. If the 3rd position of the type bill is 2 or 3, the ‘Discharge Status must be 30. ‘Discharge Status’ cannot be 30 if the 3rd position of ‘Type Bill’ is 1 or 4. If ‘Discharge Status’ is 31 or 32, there must be a number of days shown in the non-covered days field and no accommodation days charged for the leave days.

23 Medical Record Number

Record 20: Field 25

2300 / REF02 p 200

If present, should be the number used to retrieve this patient’s medical records.

24 – 30

Condition Codes

Record 41: Fields 4 - 13

2300 / HI01 thru HI12

BCBSLA will accept all valid condition codes. For adjudication, only the following codes are


UB04 Form

Locator

Field Name

192 NSFReference


p 291 – 298

needed: 02- Condition is employment related 31- Patient is a student age 18-24 attending college (full-time)

31

32 – 35

Occurrence Code and Date

Record 40: Fields 8, 10, 12, 14, 16, 18, 20, 22, 24, 26 Record 40:

2300 / HI01 – HI12

p 268 – 278

2300 / HI01 –

BCBSLA accepts all valid occurrence codes. BCBSLA accepts all valid occurrence codes; however, only the following codes will be used in claims adjudication: Code Description 01 Auto accident 02 Auto accident/no-fault insurance involved 03 Accident/tort liability 04 Accident/employment 05 Accident/other than above 11 Onset of symptoms 25 Benefits terminated by primary insurer 40 Scheduled date of admission (outpatient) 41 Date of first test for pre-admission testing (outpatient) Occurrence codes cannot be duplicated. Occurrence codes 01 – 05 is required when an accident diagnosis code is present in the principal or first other diagnosis field.

April 13, 2011 14


UB04 Form

Locator

Field Name

192 NSFReference


Fields 9, 11, 13, 15, 17, 19, 21, 23, 25, 27

HI12 p 268 - 278

Accident diagnosis codes are: 800 through 995.9 (excluding 995.3) V15.5, V15.6, V15.85, V71.3 - V71.6, 525.11 - 692.71, 692.76 - 692.77, 692.82, 733.10 to 733.19, 733.93-733.95. If revenue code 450 is present, occurrence code 01 – 05 OR 11 must be present. The occurrence date is the date that corresponds with the preceding occurrence code. Occurrence date must be present if an occurrence code is reported. If occurrence code 01-05, 11 OR 41 is used, the occurrence date must be equal to or prior to the covered from date. If occurrence code 40 is present, the date cannot be prior to or equal to the covered from or thru date.

36 Occurrence Span Code and Dates

Record 40: Field 22, 25 Record 40:

2300 / HI01 – 1 thru HI12 - 4 p 257 - 266

2300 / HI01 – 1

Allowed on outpatient claims only. BCBSLA will accept all valid occurrence span codes. Only Span Code 72 will be used for adjudication.

April 13, 2011 15


UB04 Form

Locator

Field Name

192 NSFReference


Field 23, 24, 26, 27

thru HI12 - 4 p 257 - 266

If Span code 72 is present, one or more of the following revenue codes must be present on claim:

33X, 420, 430, 440, 820, 821, 830, 831, 840, 841, 850, 90X

If occurrence span code is present, then the occurrence span dates must be present and a valid date on or prior to current date.

In the “From” field, enter the first date the patient was treated for this condition. In the “Through” field, enter the last date the patient was treated for this condition.

37 Internal Control Number

Record 31: Field 14

2300 / REF01 F82300 / REF02

p 192

Must be present if 3RD position of type bill is 5 or 7 (adjustments) Must be the 7thposition claim number found on the BCBSLA payment register or the paid/rejected screens on iLinkBLUE. Cannot be present if 3RD position of type bill is NOT 5 or 7.

38 NA

39 – 41

Value Codes and Amounts

Record 41: Field 16 - 39

2300 / HI01 – HI12

p 281 - 288

BCBSLA accepts all valid value codes; however, only the following codes will be used for claims adjudication:

April 13, 2011 16


UB04 Form

Locator

Field Name

192 NSFReference


Code Description AA Louisiana Mandated Service Chg 37 Pints of blood furnished 38 Blood deductible pints 39 Pints of blood replaced 45 Accident hour Value Code AA should be present on all inpatient claims. On inpatient claims, value amount should reflect charge of $2.00 per covered day. Value Code AA should be present on outpatient claims if surgery CPT4 code is present or if diagnosis codes V641-V643 are present on claim. On outpatient claims, value amount should be $1.00. If occurrence code 01-05 is present, then value code 45 (accident hours) must be present. If revenue code 380, 381, or 382 is present, then value code 37 (pints of blood furnished) and value amount is required. If a value code is present, then a value amount is required. If the amount does not represent a dollar amount, two zeros should be entered following the

April 13, 2011 17


UB04 Form

Locator

Field Name

192 NSFReference


number. Example: If the patient received three (3) units of blood, enter 300. If value code 45 is present, value amount must be present and must indicate the hour the accident occurred. Value amount must equal 0000-2300 OR 9900 Example: Accident hour 5:45pm use code 17 for admit hour, followed by two zeros. If value code 37 is present, then the value amount must be equal to the sum of the units for revenue codes 380, 381, and 382.

42 Revenue Code

Record 50 Fields 5, 11, 12, 13, Record 60: Fields 5, 15, 16 Record 61: Fields 5, 15, 16

2400 / SV201 p 446

A revenue code must be present on each line before revenue code 001. All 3 position revenue codes must be preceded by a zero (0). Do not include revenue code 001 representing total charges. Total claim charge is reported in Loop 2400 CLM02. Revenue codes can be duplicated on an inpatient claim only if the rates differ. Revenue codes can be duplicated on an outpatient claim only if the HCPCS or line item service dates are different.

April 13, 2011 18


UB04 Form

Locator

Field Name

192 NSFReference


If type bill is inpatient (X1X) then accommodation revenue code(s) must be present: 110-119, 120-129, 130-139, 140-149, 150-159, 160-169, 200-219, 170-174, 179, 190-194, OR 199 When ambulance HCPCS A0428, A0429, A0427 A0425 are present, then one of the following valid ambulance revenue codes must be present 540 – 545 or 549 On newborn ‘sick’ baby claims, the following nursery revenue codes can be billed.

170, 171, 172, 173, 174, OR 179 No other accommodation revenue codes are allowed. Professional revenue codes 960-964, 969, 970-979, 981-989 must be filed on a 1500 or 837P claim

43 Description N/A

April 13, 2011 19


UB04 Form

Locator

Field Name

192 NSFReference


44 HCPCS/Rates Record 50: Field 6, 11, 12, 13 Record 60: Field 6, 15, 16 Record 61: Field 6, 15, 16 Modifier Record 60: Field 7, 8, 15, 16 Record 61:

Rate 2400 / SV206

p 449

HCPCS 2400 / SV202 - 2

p 447

Modifier 2400 / SV202 – 3thru SV202 – 6

p 447 - 448

Rates: Must be at least 3 numeric positions. The following revenue codes require rates: 071, 100-101, 111-117, 119 120-127, 129 130-137, 139 140-147, 149 150-157, 159 710-173, 174, 179 190-194, 199 200-204, 206-209 210-214, 219, 381, 382. Rates multiplied by units must equal charges. Must be the appropriate CPT4 or HCPCS code that describes the service rendered. Must be a valid and current code. A valid CPT/HCPCS code must be present when outpatient surgical, diagnostic or therapeutic procedures are performed. Billing criteria vary and are based on the specific contract provisions in effect for your facility. Please refer to the BCBSLA contract. When one of the following revenue codes 540 – 545 or 549 are present, then one of the following HCPCS must be present: A0428, A0429, A0427

April 13, 2011 20


UB04 Form

Locator

Field Name

192 NSFReference


Field 7, 8, 15, 16

OR A0425. Modifier If present, must be valid and current. BCBSLA will accept all valid modifiers; however, only the following modifiers will be used in the processing of claims. 20, 22, 26, 32, 47, 50, 51, 52, 54, 55, 56, 62, 66, 75, 76, 77, 78, 79, 80, 81, 82 or 99.

45 Service Date Record 61: Fields 13, 15, 16

2400 / DTP02 / D8

2400 / DTP03 p 457 - 459

To meet HIPAA requirements, a service line date must be present for all outpatient revenue codes. For accurate processing by BCBSLA, the service line date must be present if the FROM and THRU dates are different and one of the following revenue codes is present:

330, 331, 333, 335, 339, 340-342, 349, 420-449, 550, 551, 552, 559, 610-619, 900-902, 909-910, 912-916 and 943.

April 13, 2011 21


UB04 Form

Locator

Field Name

192 NSFReference


46 Units of

Service

Record 50: Fields 7, 12, 13 Record 60: 9, 15, 16 Record 61: Fields 9, 15, 16

2400 / SV205 p 449

Inpatient Billing: The following revenue codes require units when the second position of type bill is “1”: 071, 100-101, 110-189, 200-204, 206-209, 210-214, 219, 380-382, 389 Outpatient Billing: The following revenue codes require units when the second position of type bill is “3”: 300-309, 310-319, 320-329, 330-339, 340-349, 350-359, 381-389, 400-409, 420, 430, 440, 610-619, 820, 830, 831, 840, 841, 850, 851, 900, 901, 902, 903, 909 The sum of units indicated for accommodation revenue codes (110-169, 200 – 219) and leave of absence revenue codes (180 – 189) must equal the number of covered days. EXCEPTION: When combining charges for mothers and newborn baby’s claims, the units for the accommodation revenue codes for the mother must equal to the covered days. For additional instruction on maternity-related claims, see the Maternity Claims section. Units for Louisiana Mandated Service Charge (Revenue 071) on inpatient claims must equal covered days. Units for Louisiana Mandated Service Charge on outpatient surgical claims

April 13, 2011 22


UB04 Form

Locator

Field Name

192 NSFReference


must equal 1. Units multiplied by the rate must equal the charges.

47 Total Charges

Record 50: Fields 8, 11, 12, 13 Record 60: 10, 15, 16 Record 61: Fields 10, 15, 16 Record 90: Field 13

2400 / SV203 p 448

2300 / CLM02 p 159

A charge must be present for each revenue code indicated unless multiple surgical procedures are performed. Total charges cannot be greater than $999,999.99. Do not include revenue code 001 representing total charges. Total claim charge is reported in Loop 2400 CLM02.

48 Non-covered Charges

Record 50: Field 9, 11, 12, 13

2400 / SV207 p 449

Must indicate the non covered charges when a portion of a patient’s stay is non-approved.

49 NA

50 Payer Record 30: Field 8b Record 30: Field 9

2010BC / NM103p 127

2010BC / NM109

p 128

Payor name must be present and should equal ‘Blue Cross.’ Data element 2010BC NM109 must equal 53120.

April 13, 2011 23


UB04 Form

Locator

Field Name

192 NSFReference


51 Provider Number

Record 10:Field 9

2010BC / REF02p 133

Enter the 9-digit NPI facility number or the 5-digit provider number assigned by BCBSLA for the unit of your facility where services where rendered.

52 Release of Information

Record 30: Field 16

2300 / CLM09 p 161

Indicates that you have signed written authority to release medical or billing information for purposes of claiming insurance benefits.

53 Assignment of Benefits

Record 30: Field 17

2300 / CLM08 p 160

Enter one of the following codes to indicate who will receive payment for the claim: Y - Assignment/payment to provider N - Assignment/payment to subscriber

54 Prior Payments

2320 / AMT02 p 371

Must be the total amount paid by the primary insurer when BCBSLA is secondary.

Refer to the 837I Implementation Guide for complete details on submitting claims with BCBSLA as the secondary payer.

55 Estimated Amount Due

Not used by BCBSLA

56

57

58 Insured’s Name

Record 30: Field 12, 13, 14

2010BA / NM103, 104, 105

p 109

Must be the member’s name exactly as it appears on the BCBS identification card.

April 13, 2011 24


UB04 Form

Locator

Field Name

192 NSFReference


April 13, 2011 25

59 Patient’s

Relationship to Insured

Record 30: Field 18

2000B / SBR02 p 103

2000C / PAT01 p 142

Must be the 2-digit code indicating the patient’s relationship to insured.

60 Certificate – SSN – HIC – Identification Number

Record 30: Field 7

2010BA / NM108 (MI)

2010BA / NM109 p 110

2010CA / NM108 (MI)

2010CA / NM109 p 147

2330A / NM109 p 403

Enter the subscriber’s identification number exactly as it appears on the identification card including the 3-position alpha prefix. Blue Cross and Blue Shield of Louisiana contracts All BCBSLA contract numbers will be a total of 11 or 13 positions (including the 3 position alpha prefix). When the prefix is present, the first two positions must be XU. Third position will be alpha (A-Z). Remaining member number will be 8 or 10 positions

• If the contract has 8 positions, the 7th position can be numeric or alpha (If alpha, will be A, B, N, V or X and the last position must be 1).

• If the contract number has 10 positions,

the first nine will be numeric and the 10th position can be 1-9 or C.


UB04 Form

Locator

Field Name

192 NSFReference


• Example: XUL1234567891

XUB123456X1 Out-of-Area contracts (also known as Blue Card, ITS, out-of-state National, NASCO). These contracts will begin with an alpha prefix other than XU. A valid 3-position alpha prefix must be present. EXAMPLE: YAA1234567890 Federal contracts: If contract is federal, the 1ST position must be ‘R.’ The 2ND thru 9TH positions must be numeric. If a tenth, position must be (zero) 0. EXAMPLE: R034567810

61 Insured’s

Group Name Record 30: Field 11

2000B / SBR04 p 103

2320 / SBR04 p 363

To meet HIPAA requirements, a group name or group number must be present. BCBSLA does not require group names for processing. If group name is not available, you may type “none.”

62 Insurance Group Number

Record 30: Field 10

2000B / SBR03 p 103

2320 / SBR03 p 363

To meet HIPAA requirements, a group number or group name must be present. BCBSLA does not require group number for processing. If group number is not available, you may type “none”.

April 13, 2011 26


UB04 Form

Locator

Field Name

192 NSFReference


April 13, 2011 27

63 Treatment Authorization Code

Record 40: Field 5

2300 / REF01 (G1)

2300 / REF02 p 199

Enter the BCBSLA pre-certification number when available.

64 Employment Status Code of Insured

N/A

65 Employer Name

N/A

66 Employer Location

N/A

67

68 –

Principal Diagnosis Other Diagnosis

Record 70: Field 4 Record 70: Field 5 thru 12

2300 / HI01-1 (BK) and HI01-2

p 228

2300 / HI01 – 1(BF) and HI01 –

All diagnosis codes must be current and valid ICD-9 codes for the “Covered Thru Date” of claim. ICD-9 diagnosis codes cannot be duplicated. The principal diagnosis code must be present on all claims. The first position should contain “V” or a numeric character. The second and third positions must be numeric with no punctuation. Fourth and fifth positions must be numeric or blank. If the sex is “M,” the first two positions cannot be 62 or 63.


UB04 Form

Locator

Field Name

192 NSFReference


75

76

Admitting Diagnosis

Record 70: Field 25

2 thru HI12 p 232

2300 / HI02 – 1 (BJ) and HI02 –

2 p 228

If the sex is “F,” the first two positions cannot be 60. The 837I version 4010 allows up to 24 ‘Other Diagnosis’ codes. BCBSLA adjudication system will recognize the Principal Diagnosis and first 8 ‘Other Diagnosis’ codes reported. Other diagnosis codes must be numeric or begin with “E” or “V.” If diagnosis code 905X is present (late effect of fracture), the date of accident reported with occurrence code 01 – 05 must be prior to the covered date. Admit diagnosis must be present on inpatient claims.

77 E-code Diagnosis

Record 70: Field 26

2300 / HI03 – 1 (BN)

HI03 – 2 P 229

Not used by BCBSLA

78 NA

79 NA

April 13, 2011 28


UB04 Form

Locator

Field Name

192 NSFReference


80 and 81

Principal Procedure Code and Date Other Procedure Codes and Date

Record 70: Field 13 and 14 Record 70: Field 15 thru 24

2300 HI01 – 1 (BR)

HI01 – 2 P 242 Date

HI01 - 3

2300 HI01- 1 (BQ)

HI01 – 2 Thru HI12 – 3

The 837I version 4010 allows one principal procedure code and up to 24 ‘Other” procedure codes. BCBSLA adjudication system will recognize the principal procedure and the first 5 “Other” procedure codes reported. All procedure codes must be current and valid ICD-9 codes. Principal procedure must be present on inpatient claims containing surgical revenue codes (revenues 36X, 370, 379, 710) unless a diagnosis code from the range V64.1 – V64.3 is present. For each procedure code reported, a valid date must be present and must be within the covered From and Thru date range.

82 Attending Physician ID and Name

Record 80: Field 5, 9

2310A REF01 (1A)

REF02 P 322

2310A NM103 – NM105 p 326

To meet HIPAA requirements, the attending physician ID and name must be present. However, BCBSLA does not require attending physician information for claim adjudication.

83 Other Physician ID and Name

Record 80: Field 6, 11

2310B REF01 (1A)

REF02 P 333

To meet HIPAA requirements, the ‘Other’ physician ID and name must be present. However, BCBSLA does not require attending physician information for claim adjudication.

April 13, 2011 29


April 13, 2011 30

UB04 Form

Locator

Field Name

192 NSF Reference


Notes

2310B NM103 NM105

P 328 84 Remarks Record

90: Field 4

2300 NTE01 (ADD) NTE02 p 208

The ‘Remarks’ field must be completed if the 3rd position of type bill is ‘5’ or ‘7’. If the third digit of a revenue code is “9” or if revenue codes 920 or 940 are present enter a description and the charge in remarks. If occurrence code 01 - 03 or 04 is present, but no accident diagnosis (525.11, 692.71,692.76, 692.77, 692.82 733.93 to 733.95 and 733.10 to 733.19, 800-994, 995.2, 995.4, 995.9, V15.5, V15.6, V15.85, V71.3-V71.6) or a diagnosis code beginning with an “E” other than E903-E9049, E9300-E9499 or E9500-E959 is present in principal diagnosis or diagnosis 1, then enter type of accident and date and time of accident in remarks field. The “Remarks” field cannot contain information unless required. If you feel the information entered should be accepted, please call 225.291.4334 for a determination on edit change.


V. Special Billing Requirements Home Health Claims 1. Revenue code 261** must have one of the following valid modifiers present:

BP, BU, BR, LL, NU, QR, RR, UE, NR 2. The revenue codes accepted by BCBSLA from participating home health agencies are shown below. The appropriate HCPCS or CPT codes listed in the chart below must be included in field 44 of the UB-04 when billing with their corresponding revenue codes (as shown below). This is necessary for proper pricing and payment of the service.

Accepted Revenue Codes HCPCS/CPT codes

258 J0000 thru J9999, B4150 thru B5200

261** E0781 thru E0784, E1520, K0284, A4220

264 A4230 thru A4232, A4221, A4222, B4034 thru B4085, B9000 thru B9999, K0110 thru K0111

271 A4206 thru A6406 272 A4206 thru A6406 274 L0000 thru L4999, L5000 thru L9999 291 E0100 thru E1406, E1700 thru E1830 292 E0100 thru E1406, E1700 thru E1830 293 E0100 thru E1406, E1700 thru E1830 294 E0100 thru E1406, E1700 thru E1830 300 thru 319 80002 thru 89399, 36415, G0001,

G0058 thru G0060 421, 424, 431, 434, 441, 444, 550, 551, 552, 559, 561, 571

600 E0424 thru E0480 E0500, E0600, E0601E0550 thru E0585 E1353 thru E1406

900 thru 999 Services and procedures (HCPCS/CPT) not listed on this table will be reimbursed at the lesser of the billed charge or an amount established by BCBSLA. The presence of a revenue code or fee on this listing is not to be interpreted as meaning that the patient has coverage or benefits for that service.

April 13, 2011 31


Maternity Claims Mother and Baby Discharged on the Same Date Member providers must submit combined billings for mothers and newborns that are discharged on the same date.

1. Nursery revenue codes (170-174, 179, 113, 123, 133, 143, 153) must be equal to or less than the units shown for the mother’s accommodation codes (110-119, 120-129, 130-139, 140-149, 150-159, 160-169, 200-219.)

2. If delivery of twins, the units indicated for nursery revenue codes can be up to double the amount of units indicated for the mother’s accommodation. However, the diagnosis of 651.01 or V27.2 must be in the principal diagnosis or the first diagnosis field.

3. If delivery of triplets, the units indicated for nursery revenue codes can be up to triple the amount of units indicated for the mother’s accommodation. However, the diagnosis code of 651.10, 651.11 or 651.13 must be in the principal diagnosis or the first diagnosis field.

4. If delivery of quadruplets, the units indicated for nursery revenue codes can be up to four times the amount of units indicated for the mother’s accommodation. However, the diagnosis codes of 651.20, 651.21, or 651.23 must be in the principal diagnosis or first diagnosis field.

Mother and Baby Discharged on Different Dates If the mother and baby are not discharged on the same day, their charges cannot be combined on one claim. You must bill one claim for the baby and one claim for the mother.

April 13, 2011 32


Present on Admission Indicators

Effective 1/1/10 837I Version 4010A1 Submission Instructions: The K3 segment in the 2300 Loop is designated for POA indicators. “POA” is always required first, followed by a single indicator for the principal and secondary diagnoses reported on the claim. The principal diagnosis is always the first indicator after “POA.” Next, POA indicators for the secondary diagnoses are listed in corresponding order to the secondary diagnosis codes entered. The last secondary diagnosis or ECI POA indicator is followed by the letter Z to indicate the end of the data element, If ECI diagnosis codes are submitted, POA indicators for the ECI codes must be listed in corresponding order to the ECI diagnosis codes and should follow the Z which ends the POA indicators for the other diagnosis codes. See example below: K3*POAYYYYNZ~

April 13, 2011 33


VI. Reports Generated from Clearinghouse The BCBSLA Clearinghouse provides a series of reports to assist in the tracking and monitoring of transactions. Clearinghouse reports are a critical part of the electronic submission process. The Trading Partner is responsible for monitoring all reports to ensure that all transactions were received and accepted for processing by BCBSLA. In addition, the Trading Partner is required to take corrective action when necessary. All questions regarding reports should be directed to EDI Customer Operations at: 225-291- 4EDI (4334) or email [email protected]

We recommend that you maintain a copy of these reports for at least 60 days. Summary of Reports Generated from Clearinghouse:

1. Communication Reports a. TA1 Interchange Acknowledgement (all X12 transactions)

2. Functional Acknowledgement Report a. 997 (all X12 transactions) b. BCCLREDI X12 Error Report (only for X12 transactions with errors)

3. Claims Submission Validation Reports a. Accepted/Not Accepted (for all Claims transactions only) b. Accepted/Not Accepted (for Facets Claims only)

4. Activity Log

The Activity Log is available from the submitter’s mailbox. The log lists files/reports that were sent and received Each listing provides the file/report name, date and time of the transmission, protocol used and the size of the file. See Exhibit F for an example of an Activity Log.

5. BCTPERR Report

This report is generated anytime the submitter ID within the transaction does not match the mailbox or the Test/Production indicator does not match the file, or the claim filing indicator is not equal to BL, or the CLM segments within one ST-SE exceeds 5000. See Exhibit G for an example of a BCTPERR Report.

6. DIR

This command is used as a directory to view all activity in the trading partner’s mailbox.

April 13, 2011 34


Communication Reports Communication Reports are an immediate acknowledgement of successful communication and receipt of transmitted files. They are the first step in the reconciliation process. They are not an indication that the transmitted files were accepted for processing. The Trading Partner is responsible for monitoring the reports and ensuring that all transactions submitted were received by the BCBSLA Clearinghouse. If you do not receive a communication report, we did not receive the transmission and the transmission will need to be resent. You may refer to the Activity Log that is available from your mailbox to review the status of previous submissions. TA1 Interchange Acknowledgement The TA1 provides the status of an X12 interchange header and trailer. Positive TA1 acknowledgements will not be utilized by BCBSLA. Trading Partners will automatically receive a negative TA1 for files that cannot be processed or submitted for HIPAA validation. See Exhibit A on the following page for an example of a negative TA1.

April 13, 2011 35


Example of TA1 Interchange Acknowledgement Report (all X12 transactions) Exhibit A: Negative (Rejected) TA1 Report ISA*00* *00* *ZZ*BCBSLA001 *ZZ*T0001098 *090625*1320*U*00401*000000067*0*T*:~ TA1*000019998*090602*0913*R*009~ IEA*0*000000067~

April 13, 2011 36


Functional Acknowledgment Reports 997 The 997 report is available for all X12 transactions and indicates the validity of a standard transaction. Trading Partners will be able to pull this report the next time they connect to the BCBSLA Clearinghouse. If the 997 contains a rejected status, in many cases the trading partner will receive a BCCLREDI X12 Error Report (see below) with detailed error descriptions. However, a 997 that rejected due to errors in the "Control Structure" will only create the 997 Reject. A BCCLREDI X12 Error Report WILL NOT be generated on this X12 transaction with Control Structure errors. A duplicate file is identified by the number received in the BHT03 segment. On rejected 997’s the trading partner must make the corrections and retransmit the file. See Exhibits B and C for examples of accepted and rejected 997 reports. BCCLREDI X12 Error Report The X12 Error Report indicates the validity of files submitted in the 837 format. Files that do not meet standard HIPAA compliancy will be rejected. The report will include the data contained in your file as well as specific error information. See Exhibit D for an example of the BCCLREDI X12 report. When an 837 file fails HIPAA validation, the entire file has failed and the trading partner will receive a Claredi Report. This report is in an .html format. In order to correct the errors and resubmit the file, you must do the following:

• Copy and paste the Claredi report into a word document • Click Control F, and do a find on all H1 and H2 errors within the Claredi

file. These errors will be highlighted in RED in the file • H1 and H2 errors are for syntax and format, and are the only two types of

errors that BCBSLA uses to validate HIPAA validation. • Correct any H1 or H2 errors within the 837 file, and resubmit the file to

BCBSLA NOTE: All reports will be names #########.DAT, where #########is a sequential unique number. The BCCBLREDI will need to be renamed from a .DAT to .HTML to view the X12 errors properly in Internet Explorer.

April 13, 2011 37


Examples of the 997 Functional Acknowledgement Reports

Exhibit B: Accepted 997 Acknowledgement

ISA*00* *00* *ZZ*BCBSLA001 *ZZ*T0001098 *090618*0844*U*00401*000000049*0*T*:~ GS*FA*BCBSLA001*T0001098*20090618*0844*24*X*004010X096A1~ ST*997*0001~ AK1*HC*17999~ AK2*837*00017999~ AK5*A~ AK9*A*1*1*1~ SE*6*0001~ GE*1*24~ IEA*1*000000049~. Exhibit C: Rejected 997 Acknowledgement ISA*00* *00* *ZZ*BCBSLA001 *ZZ*T0001098 *090603*1527*U*00401*000000007*0*T*:~ GS*FA*BCBSLA001*T0001098*20090603*1527*4*X*004010X096A1~ ST*997*0001~ AK1*HC*17557~ AK2*837*00017557~ AK3*SV2*2527*2400*8~ AK4*3*782*6~ AK5*R*5~ AK9*R*1*1*0~ SE*8*0001~ GE*1*4~ IEA*1*000000007~ NOTE: If the 997 contains a rejected status, in many cases the trading partner will receive a BCCLREDI X12 Error Report with detailed error descriptions. However, a 997 that rejected due to errors in the "Control Structure", or a duplicate file received, will only create the 997 Reject. A duplicate file is represented by the absence of the AK3 and AK4 segment and when the AK9 field being blank. An X12 Error Report WILL NOT be generated on this X12 transaction. A duplicate file is identified by the number received in the BHT03 segment.

April 13, 2011 38


Exhibit D: Example of the BCCLREDI X12 Error Report for an Institutional Claim ISA*00* *00* *ZZ*T0001000 *ZZ*BCBSLA001 *090602*0900*U*00401*000017557*1*T*: GS*HC*T0001000*BCBSLA001*20090602*090025*17557*X*004010X096A1 ST*837*00017557 BHT*0019*00*00017557*20090602*090025*CH REF*87*004010X096A1 NM1*41*2*BCBSLA*****46*T0001000 PER*IC*JIM DOE*TE*1234567890 NM1*40*2*BLUE CROSS*****46*BCBSLA001 HL*1**20*1 NM1*85*2*GENERAL HOSP*****24*123456789 N3*PO BOX 123456 N4*TOWN*GA*303842872 REF*1A*12345 REF*1C*123456 REF*1D*12345678 REF*1H*123456789 REF*G2*123456789 HL*2*1*22*0 SBR*P*18*0005******BL NM1*IL*1*PATIENT*GREGORY*A***MI*123456789 N3*12345 MAIN N4*TOWN*MS*395030000 DMG*D8*19470217*M NM1*PR*2*BLUE CROSS TRADITIONAL*****PI*999990228 N3*PO BOX 23071 N4*TOWN*MS*392253071 CLM*12345678*5028.8***13:A:1*Y**Y*Y*********Y DTP*434*RD8*20020614-20020614 DTP*435*DT*200206141200 CL1*3*2 REF*D9*00017557 REF*G1*21066311 REF*EA*000000755690 HI*BK:1712 HI*BH:11:D8:20090614*BH:A1:D8:19470217 NM1*71*1*DOE*SCOTT*A***24*123456789 PRV*AT*ZZ*203BG0000Y [H 2310A PRV 127 37 3 0 2000B.2300.2310A.PRV.PRV03 (null) H22003Attending Provider Specialty Code not found in Taxonomy Code Table] REF*1G*G12345 REF*1G*G12345 LX*1 SV2*0352*HC:71260*1710*UN*1 DTP*472*D8*20090614 LX*2 SV2*0352*HC:74170*1552.5*UN*1 DTP*472*D8*20090614 LX*3 SV2*0352*HC:72193*1417*UN*1 DTP*472*D8*20090614 LX*4 SV2*0636*HC:A4646*349.3*UN*2 DTP*472*D8*20090614 SE*2982*00017557 GE*1*17557 IEA*1*000017557 ********************

April 13, 2011 39


April 13, 2011 40

Claims Submission Validation Reports Accepted/Not Accepted Reports The disposition of institutional claims is detailed on the Accepted/Not Accepted Reports. This report provides detailed information on the claims that have been accepted or not accepted by BCBSLA for processing. All claims received are validated with a comprehensive set of business logic edits. The Trading Partner is responsible for reviewing these reports and taking corrective action when necessary. We recommend you maintain these reports for at least 60 days. This process evaluates the submission at the claims level.

Accepted claims are moved into the BCBSLA internal claims system for adjudication.

Not Accepted claims are rejected. These claims do not enter the processing system and must be corrected and retransmitted electronically for processing.

Accepted/Not Accepted Report for Facets Claims The disposition of Professional claims is detailed on this Accepted/Not Accepted Report. This series of reports provides detailed information on the claims that have been accepted or not accepted by BCBSLA for processing. All claims received are validated with a comprehensive set of business logic edits. The Trading Partner is responsible for reviewing this report and taking corrective action when necessary. This report differs from the original Accepted/Not Accepted Report because it will list all accepted claims as well as all not accepted claims from a Trading Partner. All claim transactions received Monday through Friday (except holidays) prior to 3 p.m. (CST) will be processed in our daily processing cycle. Accepted/Not Accepted Reports are available the following day by 9 a.m. See Exhibit E for an example of the Accepted/Not Accepted Report for Legacy claims and Exhibit H and H1 for an example of the Facets Accepted and Not Accepted Reports.


Exhibit E: Example of Accepted/Not Accepted Report for Institutional Claims

PGM=T221 BLUE CROSS & BLUE SHIELD OF LOUISIANA PAGE 1

SUBMITTER NO. T0001098 0 NAME BCBSLA SEQ

PROVIDER NO. 12345 NAME GENERAL HOSP

PROCESSING DATE 06/18/2009

CREATE DATE 06/18/2009

BLUE CROSS OUTPATIENT ACCEPTED REPORT

LAST FIRST CONT FROM THRU TOTAL CLAIM PATIENT CONTROL# NAME NAME NUMBER DATE DATE CHARGES TOB NUMBER ___________________________________________________________________________________________________

123456789 PATIENT JOHN AAA123456789 09092008 09092008 $151.25 131 123456789 DOE CHRIS XAA123456789 09092008 09092008 $136.50 131 123456789 PATIENT JANE XAA123456789 09092008 09092008 $36.00 131

NUMBER OF OUTPATIENT CLAIMS ACCEPTED IS 3 FOR $323.75 ___________________________________________________________________________________________________ PGM=T221 BLUE CROSS & BLUE SHIELD OF LOUISIANA PAGE 2

SUBMITTER NO. T0001000 0 NAME BCBSLA SEQ

PROVIDER NO. 12345 NAME GENERAL HOSP


CREATE DATE 06/18/2009

BLUE CROSS OUTPATIENT NOT ACCEPTED REPORT

LAST FIRST CONT FROM THRU TOTAL ERROR ERROR PATIENT CONTROL# NAME NAME NUMBER DATE DATE CHARGES TOB DESCRIPTION DATA ___________________________________________________________________________________________________________________________________

123456789 PATIENT JANE XAA123456789 09092008 09092008 $132.50 131 PATIENT FIRST NAME INVALID

NUMBER OF OUTPATIENT CLAIMS NOT ACCEPTED IS 1 FOR $132.50

PROVIDER TOTALS FOR SUBMISSION PROVIDER # DATE TYPE CLAIM # OF CLAIMS DOLLARS # ACCEPTED $ ACCEPTED # REJECTED $ REJECTED 12345 06/18/2009 INPATIENT 0 $.00 0 $.00 0 $.00 12345 06/18/2009 OUTPATIENT 4 $456.25 3 $323.75 1 $132.50 12345 06/18/2009 TOTAL CLAIMS 4 $456.25 3 $323.75 1 $132.50 See Appendix A for details on resolving the errors in the Error Description field.

April 13, 2011 41


Exhibit F: Activity Log ********************************************************************** LOG batch for remote user : T0001098 *********************************************************************** Wed May 7 08:25:11 2003 Add with protocol=ASYNC: ID=T0001111, BID="X12Claims.in" ...... Added successfully, bytes=36342, batch No.=638 Wed May 7 09:37:08 2003 Add with protocol=ASYNC: ID=T0001111, BID="X12Claims.in" ...... Added successfully, bytes=16334, batch No.=640 Wed May 7 09:43:23 2003 Add with protocol=ASYNC: ID=T0001111, BID="X12Claims.in" ...... Failed, returned error code=1 Wed May 7 15:17:53 2003 Extract with protocol=FTP: ID=T0001111, BID="#0000639"...... Extracted ID=T0001011, BID="<<ACTIVITY LOG>>", bytes=653, batch No.=639 ...... Successfully extracted 1 batch(es).

April 13, 2011 42


Exhibit G: BCTPERR Report The BCTPERR Report will display an error message at the beginning of the file. See boxed area below: ERROR --->>>> Mailbox ID does not match Trading Partner ID within the file Submitted <<<<ISA*00*1234567890*00*1234567890*ZZ*T0000014 *ZZ*BCBSLA001 *090601*1907*U*00401*000000032*0*T*<~ GS*HC*T0000014*RECEIVER CODE*20090601*1907*1*X*004010X098A1~ ST*837*0001~ BHT*0019*00*0001*20090601*1907*CH~ REF*87*004111111A1~ NM1*41*2*HEALTH CLINIC &*****46*T0000011~ PER*IC*RON DAVID*TE*3333333332~ NM1*40*2*BLUE CROSS BLUE SHIELD*****46*11111~ HL*1**20*1~ PRV*PT*ZZ*203BF0100X This report is generated anytime the submitter ID within the transaction does not match the mailbox, or the Test/Production indicator does not match the file, or the claim filing indicator is not equal to BL, or the CLM segments within one ST-SE exceeds 5000. Trading Partners that receive this report must correct the error and retransmit the entire file.

April 13, 2011 43


Exhibit H: Facets Accepted Report

April 13, 2011 44


Exhibit H1: Facets NOT Accepted Report

April 13, 2011 45


VII. 835 Remit Process Many trading partners utilize the electronic HIPAA 835 electronic remit retrieval process to post their payments electronically. These remits will always be dated for Monday’s. Depending on any 835 issues at BCBSLA, the remit pickup time frame could vary. The timeframe for retrieving your remits are as follows:

835 REMIT AVAILABILITY

LEGACY Monday by 2:00 pm FACETS May be available on Monday by 2:00

pm. If not, Tuesday @ noon. If you are unable to retrieve your 835 file at the above timeframes:

1) Check the ILinkBLUE system using the Remittance Advice application to determine if the paper payment register has been posted.

2) If the paper registers are not posted, this indicates that the 835 files will not be available.

3) Check the ILinkBLUE messages to determine if there is a notification alerting you to the delay.

4) If not, contact EDI Clearinghouse Support ([email protected]) and expected timeframe for availability.

If you are missing one or more 835 files:

1) If your paper remittances are posted and the above timeframes are not met for the general population, EDI will proactively notify by email trading partners and providers. If you are not able to retrieve your 835 remits by Wednesday morning and have not been contacted or no message has been placed on the ILinkBlue information board, please contact our EDI Support area at 225-291-4334 or email us at [email protected].

835 Retrieval on BCBSLA Holiday’s: 835’s are run the last workday of the week. When a holiday is on a Monday, there will be no impact to the 835 process. If the holiday is on a Friday, the process will run a day early.

April 13, 2011 46

mailto:[email protected]

mailto:[email protected]


VIII. UB04 -Type of Bill for Facets System First digit = Type of Facility Second digit = Bill Classification Third digit = Frequency of Bill Outpatient Type of Bill 13X, 14X Outpatient Hospital 23X, 24X Skilled Nursing Facility 32X – 34X Home Health 71X Rural Health Clinic 72X Renal Dialysis Facility 73X Federally Qualified Health Center 74X Outpatient Rehab Facility 75X Comprehensive Outpatient Rehab 76X Community Mental Health Center 81X, 82X Hospice 83X Hospital ASC Outpatient Surgery 85X Critical Access Hospital Inpatient Type of Bill

11X Hospital 12X Inpatient Part B Hospital 18X Swing Bed 21X Skilled Nursing Facility 22X Inpatient Part B SNF 28X Skilled Nursing – Swing Bed 41X Religious Non-Medical Facility Valid 3rd Digits 1 Full Billing 2 Interim Bill – First Claim 3 Interim Bill – Continuing Claim(s) 4 Interim Bill – Final/Discharge Claim 5 Late Charges 7 Adjustment of Paid Claim 8 Void/Cancel Paid Claim

April 13, 2011 47


IX. Not Accepted Error Definitions The disposition of Institutional (hospital) claims is detailed on the Accepted Inpatient and Outpatient Claims Report and the Not Accepted Inpatient and Outpatient Claims Reports. These reports provide detailed information on the claims that have been accepted or not accepted by BCBSLA for processing. The Electronic Data Interchange Clearinghouse Services Guide details the various reports received throughout the electronic claims process. Trading Partners are responsible for monitoring the accepted/not accepted reports to ensure that all claims submitted were received and accepted by BCBSLA, and to take corrective action when necessary. The not accepted report identifies claims with critical errors, which were not accepted for processing. All claims that appear on the Not Accepted Claims Report must be corrected and retransmitted for processing. The Error Description field on this report contains a descriptive summary of why the claim was not accepted for processing (see example below). When possible, the Error Data field will contain the specific code/data found on the claim, which caused the error. Both fields should assist you in making corrections to the claim. This section lists the errors that appear on not accepted reports and a detailed description to assist with error resolution. The Not Accepted Report provides the patient account number, patient’s last and first names, dates of service, total charge on claim, type of bill (TOB), error description and error data (data on claim that is incorrect).

April 13, 2011

Example of a Not Accepted Claims Report

C0126R03 BLUE CROSS & BLUE SHIELD OF LOUISIANA PAGE1

NOT ACCEPTED SYSTEM TO SYSTEM CLAIMS

SUBMITTER 222222222 NAME LIGHTENING CLAIMS, INC SEQ

PROVIDER NO. 12345 NAME J. DOE GEN HOSP


BLUE CROSS OUTPATIENT NOT ACCEPTED REPORT PATIENT CONTROL# LAST FIRST CONTRACT FROM THRU TOTAL TOB ERROR

Error Description Field

ERROR NAME NAME NUMBER DATE DATE CHARGES DESCRIPTION

DATA 12345678901234567 DOE JANE ABC123456789 09012009 09152009 $172.00 131 NON COVERED DAY INVALID

0000 0067

NUMBER OF OUTPATIENT CLAIMS NOT ACCEPTED IS 1 FOR $172.00

PROVIDER # DATE PROVIDER TOTALS FOR SUBMISSION TYPE CLAIM # OF CLAIMS DOLLARS #ACCEPTED $ACCEPTED #NOT ACCEPTED $ NOT

ACCEPTED

12345 10/01/2009 INPATIENT 0 $0.00 0 $0.00 0 $0.00 12345 10/01/2009 OUTPATIENT 30 $9575.00 29 $9403.00 1 $172.00 12345 10/01/2009 TOTAL CLAIMS 30 $9575.00 29 $9493.00 1 $172.00

48


NOT ACCEPTED ERROR CODES: 071 REVENUE CODE WITH NO SURGERY CPT4 CODE

071 revenue codes can only be present if surgery CPT4 is present on claim or if a diagnosis code of V641-V643 are present on claim.

071SGY

Revenue 071 can only be present if surgery CPT4 code is present on claim or if diagnosis codes V641-V643 is present on claim.

ACCIDENT HOUR INVALID

If value code 45 is present, then a value amount must be present and equal to 0000-2300 or 9900.

ACCIDENT OCC CODE NOT FOUND

If a diagnosis code is within the accident range (525.11, 692.71, 692.76, 692.77, 692.82 733.93 to 733.95 and 733.10 to 733.19, 800.00-994.9, 995.20-995.29, 995.4, 995.90-995.94, V15.5, V15.6, V15.85, V71.3-V71.6) then an occurrence code of 01-05 must be present. **NOTE: A diagnosis code beginning with an ‘E’ other than E903-E9049, E9300-E9499 or E9500-E959 is also considered an accident.

ACCOM REV CODE MUST BE PRESENT (TYBLRM)

If Inpatient bill, then a valid accommodation revenue code of 0100-0169 and 0190 - 0219 or nursery accommodation revenue code (0170-179) must be present.

ACCOM UNITS NOT EQ TO COV NONCOV DAY (ACCOMCOV) 1. If this is an inpatient bill, the sum of units for all accommodation

revenue codes (0100, 0101, 0110 - 0169) must be equal to the covered days. 2. If this is an inpatient bill and a leave of absence revenue code (018X) is present, then the units for the leave of absence revenue code must be equal to the non-covered days.

ADJCLM PROCESSING WAIT UNTIL COMPLETE (ADJNPROC) Provider must allow original adjustment claim to be processed prior to entering another adjustment. (This edit will be issued if a claim indicates it’s an adjustment and an ICN number is present on the claim).

ADJ CLM REQS ICN CLAIM NUMBER (ADJICNRQ)

When submitting an adjustment claim, the internal claim number is required (ICN)

April 13, 2011 49


ADMIT DIAGNOSIS REQUIRED (ADMDIAG) Admit diagnosis is required to out of state contracts only if revenue code is 450 thru 453, 456, 459,516, 526 or 726 and type bill 1-2 equal ‘13 or 85’ and type admission equal ‘1’ or ‘2’ or ‘5’

ADMIT DT GREATER THAN FROM DT

The Admission Date cannot be greater than the Statement from Date. ADMIT DATE INVALID (ADMDATE)

1. If outpatient bill and admit date is present, it must be numeric. Admit date is not required on outpatient claims.

2. If inpatient bill and third position of the type of bill is 1 or 2 admit date

must be present and equal to statement from date.

3. If inpatient bill and the third position of the type bill are 3 or 4 admit date must be present and less than statement from date.

4. If inpatient bill and third position of the type of bill is 5, 6, 7, or 8 admit

date must be present and cannot be greater than statement from date. ADMIT HOUR INVALID

1. Must be present on all inpatient claims and a valid Admit Hour. 2. Must be four numeric positions indicating hour and minute of

admission (hhmm). ADMIT HOUR MUST BE 00 THUR 23 (ADMITHR)

Admit hour is required. If the claim is inpatient the admit hour must not be blank and must be equal to 00-23 (applies to only out of state contracts)

AMBULANCE HCPCS REQS VALID AMB REV CODE (AMBREV)

A valid ambulance HCPCS code must be present when revenue code 0540-0549 is present.

AFTER PROV. TERMINATION DATE The BCBSLA provider number must be effective for the date of service filed on claim.

ASSIGNMENT OF BENEFITS MISSING OR INVAL (ASGBEN)

The assignment of benefits indicator must be a Y or an N to indicate if the benefits are assigned.

BEFORE PROVIDER EFFECTIVE DATE The BCBSLA provider number must be effective for the date of service filed on claim.

April 13, 2011 50


BLOOD FURNISHED INVALID The units for revenue codes 380, 381 or 382 must be equal to the value amount for pints of blood furnished (value code 37.)

BLOOD REPLACED INVALID

The value amount of replaced pints of blood (value code 39.) must be equal or less than the value amount for furnished pints of blood (value code 37).

CHARGE = 0

1. If revenue code is duplicated to show multiple procedures, both codes must have a surgical CPT code. If not, a charge must be entered.

2. If a surgery revenue code is duplicated, a charge must be present by at least one of the surgery revenue codes.

3. On inpatient claims, must be present for each revenue code. CONDITION CODE 31 VS DOB

When condition code 31 (patient full time student age 18-24), the patients date of birth subtracted from current date should be 18-24.

CONFLICT WITH ADM DT AND FRM DT AND TYBL (ADMDATE)

• If this is an outpatient bill, the admission date can be present but is not required and must be numeric.

• If this is an inpatient bill and the third position is = to a '1' or '2', the admission date must be present and must equal to the statement from date

• If this is an inpatient bill and the third position is = to a '3' or '4', the admission date must be present and must be less than the statement from date

• If this is an inpatient bill and the third position is = to a '5', '6', '7', or '8', the admission date must be present and cannot be greater than the statement from date

CONT NO PREFIX INVALID FOR DOS (PREFX)

Contract number prefix is invalid for Date of Service (will apply only to out of state contracts)

CONT# PT SEX CONFLICTS

The relationship to the insured must be must be SE, HU, WI, or DE. It cannot be WI if the sex is male (M), and cannot be HU if the sex is female (F).

April 13, 2011 51


CONTRACT NUMBER INVALID If Blue Cross Blue Shield of Louisiana (BCBSLA) Contract:

It must be found on the BCBSLA eligibility file and can be 8, 10, 11, or 13 positions. If 1ST and 2ND positions are alpha:

1. The first two positions must be XU. 2. The 3RD position must be alpha (A-Z) 3. The 4TH thru 9TH positions must be numeric 4. The 10TH position must be numeric, A, B, N, or X. 5. If 10TH positions is A, B, N, or X, the 11TH position must

be numeric and remaining positions blank. Examples: XUA123456X1 XUK123456B1

If 1ST -3RD positions are not alpha 1. 1ST - 6TH positions must be numeric 2. 7TH position must be numeric or A, B, N, or X. 3. If 7TH position is A, B, N, or X, the 8TH position must be

numeric and remaining positions blank. 4. If 7TH positions are numeric, then 8TH position must be

numeric. 5. If 8TH position is numeric and 9TH position is present, then

9TH position must be numeric. 6. If 9TH position is present, then the 10TH position must be

present and numeric (1-9) or C

If contract is OUT OF STATE (out of area) a valid alpha prefix must be present.

Example: YAA123456789

If contract is FEDERAL, the 1ST position must be ‘R’ and the 2ND thru 9TH positions must be numeric.

Example: R034567810 CONTRACT SECONDARY TO MEDICARE

The member’s contract number is secondary to Medicare. Please file Medicare primary.

April 13, 2011 52


COVDY BLNK OR NOT EQ TO STMT FRM THR DT (COVDAYS)

1. If this is an inpatient bill, the covered days must be present and must be numeric. 2. If the inpatient bill type is equal to XX2, XX3, or XX4 and the statement from date is equal to statement thru date, then the covered days must equal to '1'. 3. If the inpatient bill type is equal to XX1 or XX4, then the covered days and the non-covered days must equal to the total count of days of statement from date to statement thru date minus 1. 4. If the inpatient bill type is equal to XX2 or XX3, the covered days and non-covered days must equal to the total count of days of statement from date to the statement thru date.

COVERED FROM DATE INVALID (COVFROM) 1. The “covered from” date must be numeric 2. The date must be in valid date format. 3. The “covered from” date cannot be greater than the “current date”.

COVERED FROM IS A FUTURE DATE

1. Must be a valid date on or prior to the current date. 2. Must be six numeric positions. Ex: 010196

COVERED THRU DATE INVALID (COVTHRU)

1. The “covered thru” date must be a valid date on or after the “covered from” date (first date of service.) 2. The “covered thru” date must be numeric. 3. The “covered thru” date must be on or prior to the current date.

DATE OF BIRTH INVALID 1. The DOB must be a valid date on or before the covered date or first

date of service 2. The DOB must be eight numeric positions ex: 12011958

DATE OF BIRTH MUST BE A VALID DATE (DOBVALDT)-(ITS Only) Patient’s date of birth must be present and a valid date. DIABEDU – Long Desc DIABETES DIAG REV REQS CPT4 OR HCPCS CODE

If Diagnosis Code '25000' or '64883' and Revenue Code '0942' are present, CPT '99078, G0108 & G0109, 98960, 98962,97802,97803,97804 must also be present. This applies to outpatient claims with bill type 13x only. This is a State Mandate - LSARS22; 215.21.

DIAG AND PATIENT SEX CONFLICT

1. 1ST Two positions must not be 62 or 63 if sex is M 2. 1ST Two positions must not be 60 if sex is F

April 13, 2011

53


DIAG CODE REQUIRES 4TH OR 5TH DIGIT (DX45D) The diagnosis code identified requires the fourth or fifth position to further describe.

DIAGNOSIS CODE MISSING OR INVALID (DIAGINV) Principal diagnosis code:

1. The principal diagnosis code must be present and valid for the thru date of service on the claim.

2. The principal diagnosis code cannot begin with an 'E'. Other diagnosis codes:

1. If present, must be a valid code for the thru date of service 2. You cannot skip fields in between diagnosis codes

DISCHARGE HOUR INVALID (DISCGHR)

If the claim is inpatient the discharge hour must be present and equal to 00-23 (applies only to out of state contracts)

DISCHARGE STATUS INVALID

Status: The 1ST and 2ND positions must be numeric and a code of 01-07, 20, 31, or 32.

DUPLICATE CLAIM- PREV RECEIVED

This claim was previously received by BCBSLA. Please do not resubmit. DUPLICATE DIAGNOSIS CODE

ICD-9 diagnosis code cannot be duplicated. DUP OCCURRENCE CODE FOUND

Occurrence codes cannot be duplicated. DUP OUTPATIENT CHARGE INVALID

If a revenue code, HCPCS, and charge are duplicated with the same date of service, combine the like codes and enter the correct number of units.

DXCD IS BLANK WITHIN DXCDS You cannot skip fields in between diagnosis codes.

DXL HCPCS CD REQ"S DXL REV CD

DXL HCPCS code '70000' - '76139', '76141'–‘77260', '77264'-'77418', '77421'-'77424''77426'-'77429','77431'-'78989', '78991'-'89999', 'G0030'-'G0047', 'G0056' - -'G0060', 'G0001'& '36415' is present without a DXL revenue code of 300-307,309-312, 314,319 -324,329,333,340-342,349-352,359,390,400-404,409,610-612,619

April 13, 2011 54


DXOCDT If the diagnosis code is 905X, (late effect of fracture) the accident occurrence date must be prior to the covered date.

FAX NEW ROOMRATE 225-297-2750

The rate entered on room and board exceeds the rate on file at BCBSLA. A copy of the new rates should be signed by either the business office manager, CFO, CEO or administrator and faxed to the Provider Reimbursement Department at 225.295.2750. Three days after you send the fax, the claim may be resubmitted electronically.

FEP 490 REQUIRES SAME FRM THRU

If outpatient and surgical revenue code is present, statement from and through dates must be the same.

FEP DATE OF SERVICE INVALID

If outpatient and surgical revenue code is present, statement from and through dates must be the same.

FEP REMARKS INVALID

If outpatient, when billing for revenue codes 42X, 43X, or 44X on a federal contract, the actual dates of service must be entered in the remarks field.

Ex. 421 on 8/1 8/3 8/4 8/15, 431 on 8/1 8/3 8/15

April 13, 2011 55


HCPCS 1. The CPT/HCPCS procedure code range is:

10021-10022 10040-31574 31576-36399 36416-36599 36601-69990 91000-91055

91100-91299 92511 92950-92973 92975-92998 93501-93572

99183

C1088 C1300 C9700-C9702 C9708

G0167

2. A valid CPT/HCPCS code within the code range listed in #1 above is required when revenue codes 36X, 481, 49X, 790, and 799 are billed unless ICD-9-CM diagnosis codes V64.1, V64.2, or V64.3 are present. If multiple 481 revenue codes are billed, only one of the lines has to contain a valid CPT/HCPCS code.

3. Since revenue code 071 (Louisiana Mandated Service Charge) indicates an outpatient procedure was performed, a claim without a valid CPT/HCPCS code listed in #1 will be returned.

4. A valid CPT/HCPCS code is required for the following revenue codes: 278 420, 430, 440, 45X, 471, 480, 634-636, 750, 759, 761, 829 940, and 949. The CPT/HCPCS code does not have to but can be a procedure or diagnostic or therapeutic code listed in #1 or #5. When procedures or diagnostic and therapeutic services are performed, the appropriate CPT/HCPCS code must be given.

5. The Diagnostic and Therapeutic CPT/HCPCS code range is:

36400-36415 36600 70010-89399 90939 92974 91060-91065 93000-93350 93600-96999 97010-97546 A4641-A4647 A9500-A9510 C8900-C8914 G0001 G0030-G0047

G0050 G0102-G0107 G0120-G0122 G0125 G0130-G0132 G0210-G0234 G0236-G0239 G0242-G0243 J0640 J1245 J1440-J1441 J1561-J1565 J1745 J2405

J2430 J2993-J2997 J9000 J9045 J9190 J9201 J9206 J9265 J9310 J9355 Q0136 Q0166 Q0179 Q0180

Professional-only CPT/HCPCS codes are NOT valid for billing radiological facility services. A few examples of these codes follow: 76140, 77427 and 77261-77263.

April 13, 2011 56


HCPCS (continued)

6. A valid CPT/HCPCS code is required for Diagnostic and Therapeutic Service revenue codes 30X, 31X, 32X, 333, 34X, 35X, 40X, 410-413, 46X, 482, 483, 61X, 621, 730, 731, 74X, 921 and 922.

HCPCS NOT VALID OR NOT VALID IN BC SYSTE (HCPCSINV)

The HCPCS code is invalid or not valid for the date of service on the claim

HCPCSI CPT4 code entered is invalid

1. The CPT4 code entered in the HCPCS field is invalid. Must be a valid CPT4 code.

2. Valid CPT4/HCPCS codes for radiology and laboratory are 70010-89399, G0001, G0030-G0047, G0058-G0060, 36415.

3. Valid HCPCS codes for ambulance are A0390, A0427, A0428, A0429.

HCPCSR CPT4 code required for this revenue code: 1. Revenue codes 360-369, 481, 490 or 499 require a surgical CPT4

code entered in the HCPCS/Rate field. Must be a CPT4 code from the following ranges: 10040-69979, 92975, 92982, 92986, 92990, 93501-93545, or 93561.

2. Revenue codes 480, 750, 759 requires CPT4 codes. 3. Revenue codes 30X, 31X, 32X, 333, 34X, 35X, 40X, 61X requires

CPT4/HCPCS coding. 4. Revenue codes 540, 541, 542, 543, 544, 545 or 549 require at least

one of the following HCPCS code: A0390, A0427, A0428, A0429. HCPSCR

Issued when Dialysis claim (Provider Gen Type is 18) and rev code 634 or 635 is present and - (For DOS prior to 1/1/2004) HCPCS is not Q9920 - Q9940 - (For DOS after 12/313/2003) HCPCS is not Q4054 and Q4055

HCPCSS 1. CPT4 code entered must be surgical 2. The CPT4 code entered is not a valid surgical code. Must enter a

surgical CPT4 from the following ranges: 10040 thru 69979, 92975, 92980 thru92982, 92984, 92986, 92987, 92990, 92992, 92993, 93501 thru 93529, 93536, 3539 thru 93553, 93561, and 93562, or 93561.

**EXCEPTION: CPT4 codes 36415 and 36430 are not valid.

April 13, 2011 57


ICD9 PROC CD REQ"S 490 REV CD Surgery revenue code not present on surgery. A surgery CPT4 is present with a non-surgery revenue code. Revenue code must be 360-369, 480, 481, 490, 499, 750, or 759.

ICN # INVALID Claims must be submitted with a valid ICN number.

ICN# REQUIRED When an adjustment claim is indicated, the claim must be submitted with a valid ICN number of the previously processed claim.

ICN CLM NUMBER NOT ON BC FILE (ICNINV)

The internal claim number submitted is not on file at BCBSLA.

INSURED’S NAME INVALID Insured’s name cannot be blank and cannot contain punctuation.

INVALID CONTRACT NUMBER (CONT_INV) The contract number or subscriber ID on the claim is invalid. Correct contract number and resubmit claim.

INVALID FROM DATE OF SERVICE (FDOS)

1. The “from date” of service must be a valid date on or prior to current date 2. The “from date” must be six numeric positions ex: 19960819 (4010 format) 3. The “from date” must be present if any revenue codes are given on an

outpatient claim. 4. The “from date” cannot have embedded spaces or punctuation

INVALID MODIFIER

The modifier submitted is invalid. When present, modifier must be one of the following codes: 22, 26, 32, 47, 50, 51, 52, 54, 55, 56, 62, 66, 76, 77, 78, 79, 80, 81, 82 or 99.

INVALID NEWBORN NAME (BABYNAME)

The patient’s first name field cannot contain the following: Baby, babyb, baby1, baby2, baby3, baby4, babygirl, babygirl1, babyboy, babyboy1, girl, bab1, babygirl2, babyboy2, bab2, babygirl3, babyboy3, bab3, babygirl4, babyboy4, girl1, boy1, infant1, girl2, boy2, infant2, girl3, boy3, infant3, bab4, girl4, boy4, infant4, twin1, twin2, unknown, boy, infant, twin, triplet, newbo, or any name beginning with Baby, unless the patients age is great than one. The child’s given name must be entered.

April 13, 2011

58


INVALID PREFIX FOR DATE OF SERVICE(PREFIX) Invalid prefix for date of service (applies to out of state contracts only) LINE DATE OF SERVICE INVALID IN CLAIM DATE OF SERVICE (SRVCDT)

Line date of service invalid or not in claim date of service range. This applies to out of state contracts only (applies to out of state contracts only)

LINE ITEM DOS SPANS CALYR SPLIT BILL (DOSYR)

If outpatient type bill, line item date of service for all revenue codes must be within the same calendar year.

MAIL DIRECT TO PLAN ON CARD

You have entered an out of area or national account contract that must be filed directly to the address on the subscriber ID card.

MEDICAL RECORD NUMBER MISSING

Medical Record Number is required if entering an out-of-area claim. MENTAL AND NERVOUS PROV NUM MUST BE USED (MENTNERV)

If this is an inpatient claim and the first three positions of the principal diagnosis code are equal to 290, 293 thru 302 or 306 thru 319, the claims must be submitted with the BCBSLA provider number assigned for mental and nervous claims.

MODINV The modifier indicated is invalid. When present, modifier must be one of the following codes: 20, 22, 26, 32, 47, 50, 51, 52, 54, 55, 56, 62, 66, 76, 77, 78, 79, 80, 81, 82, OR 89.

NC CHGS > THAN COV CHGS

1. Charges must be present if revenue codes are given. 2. If a surgery revenue code is duplicated to show multiple procedures,

both codes must have a surgical CPT code. If not, a charge must be entered.

3. If a surgery revenue code is duplicated, a charge must be present by at least one of the surgery revenue codes.

NON COVERED DAYS INVALID

1. Must be completed if status is 31 or 32 2. Must be completed if revenue codes 180-189 are present and must be

equal to the number shown in the unit’s field corresponding to revenue codes 180-189.

April 13, 2011 59


NSRY ACCOM UNIT CONFLICT WITH COV DAY (NRSYDAY) 1. If this is an inpatient bill and a nursery accommodation revenue code is

(017X) present and no accommodation revenue codes (0110 - 0169, 0190 - 0219) are present, then the units for nursery accommodations must equal the covered days

2. If this is an inpatient bill and the nursery accommodation revenue code is (017X) present and accommodation revenue codes (0110 - 0169, 0190 - 0219) are present, then the units for accommodation revenue codes must equal the covered days and the units for nursery accommodations must be equal to or less than the covered days.

NRSY QUAD ACCOM UNIT CONFLIC WITH COV DY (NRSYQUAD)

If this is an inpatient bill and a nursery accommodation revenue code (017X) is present and accommodation revenue codes (0110 - 0169, 0190 - 0219) are present and diagnosis Code 651.20, 651.21, or 651.23 (quadruplets) are present in the principal or first other diagnosis code field, then units for accommodation revenue codes must equal covered days and units for nursery accommodations can be up to 4 times covered days.

NRSY TRIP ACCOM UNIT CONFLIC WITH COV DY (NRSYTRIP)

If this is an inpatient bill and nursery accommodation revenue code (017X) is present and accommodation revenue codes (0110 - 0169, 0190 - 0219) are present and diagnosis code 651.10, 651.11, or 651.13 (triplets) are present in the principal or first other diagnosis code field, then units for accommodation revenue codes must equal covered days and units for nursery accommodations can be up to 3 times covered days.

NRSY TWIN ACCOM UNIT CONFLIC WITH COV DY (NRSYTWIN)

If this is an inpatient bill and nursery accommodation revenue code (017X) is present and accommodation revenue codes (0110 - 0169, 0190 - 0219) are present and diagnosis code 651.01 or V27.2 (twins) are present in the principal or first other diagnosis code field, then units for accommodation revenue codes must equal covered days and units for nursery accommodations can be up to 2 times covered days.

OCC ACCIDENT DIAG NOT FOUND

For inpatient and outpatient claims: If an occurrence code of 05 is present then a diagnosis code within the accident range (525.11, 692.71, 692.76, 692.77, 692.82, 733.93 to 733.95 and 733.10 to 733.19, 800-994, 995.2, 995.4, 995.9, V15.5, V15.6, V15.85, V71.3-V71.6) must be present in the principal diagnosis field. NOTE: A diagnosis code beginning with an ‘E’ other than E903-E9049, E9300-E9499 or E9500-E959 is considered an accident.

April 13, 2011 60


OCC-CD Occurrence codes 1-5 :

1. Must be numeric 2. An occurrence code 01 - 05 must be present if diagnosis code

found in the principal or diagnosis1 field is within the range of: 525.11, 692.71, 692.76, 692.77, 692.82, 733.93 to 733.95 and 733.10 to 733.19, 800-994, 995.2, 995.4, 995.9, V15.5, V15.6, V15.85, V71.3-V71.6. Note: Diagnosis codes beginning with an ‘E’ other than E903-E9049, E9300-E9499 or E9500-E959 are considered accident.

3. Occurrence code 01-05 must be present if accident hour is present. 4. Must be one of the following:

01 – Auto accident 02 – Auto accident/no-fault 03 – Accident /tort liability 04 – Accident/employment 05 – Accident/other than above 11 – Onset of symptoms 25 – Date benefits terminated by primary payer 41 – Date of first test for pre-admit test

OCC CD 1, 2, 3, 4. 5 OR 11 REQ

If revenue code 450 is present, occurrence code 01-05 or 11 must be present.

OCC CD 40 & 41 INVALID ON SURG

Occurrence code 40 and 41 cannot be present on a surgery claim. OCC CD 40 REQD W\ 41 ON OUTPAT

If occurrence code 41 is present, occurrence code 40 must be present OCC CD 41 REQD W\ 40 ON OUTPAT

If occurrence code 40 is present, occurrence code 41 must be present

April 13, 2011 61


OCCURRENCE CODE INVALID 1. Occurrence code must be numeric 2. If revenue code 450 is present, occurrence code 01-05 or 11 must be

present. 3. An occurrence code 01-05 must be present if diagnosis code found in the

principal or diagnosis 1 field is within the range of (525.11, 692.71, 692.76, 692.77, 692.82, 733.93 - 733.95, 733.10 - 733.19, 800-994, 995.2, 995.4, 995.9, V15.5, V15.6, V15.85, V71.3-V71.6)

NOTE: Diagnosis codes beginning with an ‘E’ other than E903-E9049, E9300-E9499 OR E9500-E959 are considered accident.

4. Occurrence code 01-05 must be present if accident hour is present. 5. Must be one of the following:

01 – Auto accident 02 – Auto accident/no fault 03 – Accident/tort liability 04 – Accident/employment 05 – Accident/other than above 11 – Onset of symptoms 25 – Date benefits terminated by primary payer 41 – Date of first test for pre-admit test

OCCURRENCE DATE IS INVALID

Occurrence Date 1. If occurrence code 01-05, 11 or 41 is used, the occurrence date

must be equal or prior to the covered from date. 2. If occurrence code 40 is present, the date cannot be prior to or

equal the covered from or thru date. 3. If revenue code 450 is present, you must indicate occurrence code

01-05 or 11 with accident date or onset of symptoms. OUT OF STATE CONT DHH FILE PAPER CLAIM (MEDICAID) (MEDICDC)

This is a Medicaid claim and must be filed on paper (will apply only to out of state contracts)

PAT STATUS PROV PPS STATUS

Discharge status vs. provider number: 1. Discharge status cannot be 30 if filing claims for a FMP (Fair

Market Pricing) Provider. 2. Claims for FMP providers cannot be split billed.

PATIENT ADDRESS NOT PRESENT

1. Must be present if not BCBSLA contract. 2. Must be present if benefits are not assigned to your facility

(assignment field contains ‘N’) 3. Must be alpha numeric.

April 13, 2011 62


PATIENT CITY INVALID Address city:

1. Must be present if contract is not a BCBSLA contract. 2. Must be present if benefits are not assigned to your facility

(assignment field contains ‘N’). 3. First two positions must be alpha. 4. Remaining positions must be alpha or blank.

PATIENT CONTROL NUMBER MISSING (PATCNTLN)

The patient control number must be present on the claim and must contain at least one character.

PAT DOB YEAR NOT ON BC FILE (PATDOBYR)

The patient’s date of birth is invalid. Please correct and resubmit. PATIENT DISCHARGE STATUS MISS OR INVALID

1. If this is an outpatient claim, data can be present but it is not required. 2. If this is an inpatient claim, the data must be present, must be a 2-

position numeric code, and must be one of the following: '00', '01' thru '08', '20', '30' thru '32', '43', '50', '51', or '61' thru '65'.

PATIENT FIRST NAME INVALID First name:

1. 1ST and 2ND positions must be alpha 2. Remaining positions must be alpha or blank

PAT FIRST NAME NOT ON BC FILE (PATFSTNM) Patient’s first name is invalid PAT LAST NAME NOT ON BC FILE (PATLSTNM) Patient’s last name is invalid PATIENT LAST NAME INVALID

Last name: 1. 1st and 2nd positions must be alpha 2. Remaining positions must be alpha or blank

PATIENT NAME DOES NOT MATCH NAME ON BC SYSTEM

The patients first name, last name and middle initial (if present) on the claim must match the BCBSLA system exactly or the patient is not valid on this contract

PATIENT RELATIONSHIP CODE IS INCORRECT The patient’s relationship to the subscriber is incorrect. Correct and resubmit claim.

April 13, 2011 63


PATIENT STATUS INVALID 1. Patient Status is required for all inpatient claims. 2. 1st and 2nd positions must be numeric and a code of 01-07, 20, 31, or 32.

PATIENT STATUS INVALID (PATSTINV)

Patient status is required if the claim is inpatient only. If the claim is inpatient the patient status cannot equal blank and must be equal to 01-07, 09, 20, 30, 40-43, 50-51, 61-66, or 70 (applies to out of state contracts only)

PATIENT’S DATE OF BIRTH IS INCORRECT

The patient’s date of birth is invalid. Correct and resubmit claim. PAYER 2

If secondary insurance information is present, then a secondary payer name must be entered.

PAYER ID/SUB ID INVALID

1. If the contract alpha prefix is not XU?, then this field must be completed. 2. If outpatient, must be completed if indicating secondary insurance

information (COB) PAYNM1

Must be present and the name of the primary payer. PRECERT DAYS APPROVED. SPLIT BILL –

If the from and thru dates entered on an inpatient stay does not match the Pre-certification on file. The claim should be split to reflect the approved days.

PRESENT ON ADMISSION INFO INVALID (POAINV)

Present on Admission Indicators must be present for and a valid code on all inpatient claims. The valid present on admission indicators are Y, N, U, W, or 1.

PRESENT ON ADMISSION INFO REQ’D OR INV (POAREQD)

Present On Admission Indicators Required OR Invalid For Acute Care Inpatient Admissions.

PROC

Procedure codes: If present, must be a valid ICD9-CM3 code. Outpatient Claims do not require a procedure code (FL80) Outpatient Claims are under our surgery reimbursement and a CPT-4 Code is required on the revenue code line (FL44). If procedure date is present, a procedure code is required.

April 13, 2011

64


PROC CD & PATIENT SEX CONFLICT Procedure code indicated conflicts with sex relationship code entered.

PROC CODE REQUIRES 3RD OR 4TH DIGIT (PROC34D) The third or fourth position is required to further describe the procedure performed. PROCEDURE CODE INVALID (PROCINV)

The procedure code is not on file or is invalid for the date of service on this claim. Procedure codes should not be present on outpatient claims. They are allowed, but if present, must contain a valid ICD9-CM3 code.

PROCEDURE DATE MISSING OR INVALID (PROCDATE) 1. If the procedure code is present, then the procedure date is required. 2. The procedure date must be valid and on or between the statement

covered from and thru date. 3. If the procedure date is present, then the procedure code is required.

PROF?

Professional claim: 1. Must be ‘Y’ OR ‘N’ 2. Must by ‘Y’ if BCBSLA handles the professional coverage.

PROV NO INVAL OR PROV NOT EFFECT FOR DOS

The BCBSLA provider number must be effective for the date of service filed on the claim

PROVIDER NUMBER NOT IN TABLE The provider number submitted on this claim is not set up to submit electronic claims to BCBSLA. Please contact BCBSLA EDI department at 225. 291.4334.

PROVIDER NUMBER NOT ON FILE

The Provider Number must be the 5-digit provider number assigned by BCBSLA to the provider, facility or the designated provider sub unit providing the billed services.

PROVIDER TERMINATED

The BCBSLA provider number must be effective for the date of service filed on claim.

PTCT# 1

1ST Position of the patient control number must be completed.

April 13, 2011 65


R&B DAYS EXCEED COVFM&THRU DTE Units of the accommodation revenue codes are greater than the number of covered days.

RATE

1. Rate must be at least 3 numeric positions 2. Must be present if one of the following revenue codes are used: 071, 100-

101, 110-117, 119,120-127, 129, 130-137, 139, 140-147, 149, 150-157, 159, 170-174, 179, 200-204, 206-209, 210-214, 219, 381, 382, 389

REL

Patient’s relationship to insured must be valid and present. RELATION TO INSURED INVALID

1. If patient is not the insured, you must complete this field. 2. If entered, must be 01-05, 10, 13, OR 16.

RELEASE OF INFORMATION MISSING OR INVALID (RELINFO)

1. Release of Information must be present and must be equal to 'Y' if you are filing electronically.

2. If it is an ‘N’, the claim must be filed hardcopy.

REMARKS MISSING 1. If a revenue code ends in ‘9’, enter description and charge in remarks. 2. If 3RD position of type bill is ‘7’ or ‘8’, enter required information for

adjustments/late charges. 3. If occurrence code 01 - 03 or 04 is present, but no accident diagnosis

(525.11, 692.71,692.76, 692.77, 692.82 733.93 to 733.95 and 733.10 to 733.19, 800-994, 995.2, 995.4, 995.9, V15.5, V15.6,V15.85, V71.3-V71.6) or a diagnosis code beginning with an ‘E’ other than E903-E9049, E9300-E9499 or E9500-E959 is present in Prin Diag or Diag 1, enter type of accident, date and time of accident in remarks field.

4. If outpatient, when billing for revenue codes 42X, 43X, or 44X on a Federal contract, the actual dates of service must be entered in the remarks field. EX: 421 ON 8/1 8/3 8/4 8/15, 431 ON 8/1 8/3 8/15

REMARKS NOT REQUIRED

The remarks field cannot contain information unless required. If you feel the information entered should be accepted, please call 225.291.4334 for determination on edit change.

April 13, 2011 66


REV CODE 0071 TAX DAYS TOO BIG 1. On inpatient claims the rate per day for revenue code 071 is $2.00. The

units indicated for revenue code 071 cannot exceed the covered days. 2. For outpatient surgery claims the rate for 071 revenue code is $1.00 and

the unit of service must equal 1. REV CODE 0071 CHARGE INVALID

The 071 revenue code for Louisiana Mandated Service Charge can only be submitted on inpatient claims or Outpatient Surgical Claims only.

REV CODE NOT PRESENT

A revenue code must be present on each line before revenue code 001. REVENUE CODE 0001 NOT PRESENT

Revenue code 001 must be present. REVENUE CODE INVALID

Inpatient Revenue Codes 1. Must have valid revenue code present. 2. Revenue code must be 3 numeric positions or blank 3. Revenue code must be present preceding 001 revenue code.

4. Must be valid and not one of the following:

000 473-475, 477, 478 002-009 484-488 019-069 491-498 070, 072-099 501-508 118 513-518 128 524-528 138 532-538 148 546-548 158 561-569 160-169 590-599 175 600-609 190-199 620, 622-623,625-629 205 639 215-218 640-649 225-228 653, 654, 657, 658 236-238 660-669 241-248 670-679 254-255 680-689 262-268 690-699 276 701-708 281-289 711-718

April 13, 2011 67


REVENUE CODE INVALID (continued) 293-298 725-728 308 732-738 313, 315-318 741-748 322, 323, 325-328 751-758 334, 336-338,343-348 770-779 353-358 780-789

363-366, 368 790-799 371-373, 375-378 805-808 388 815-818 393-398 890-899 403-408 904-908, 913 411, 414-418 925-928 425-428 930-939 435-438 948 445-448 950-959

451-455, 457, 458 460, 461 960-989

Outpatient Revenue Codes 1. Must have valid revenue code present. 2. Revenue code must be 3 numeric positions or blank. 3. Must be valid and not one of the following:

002-009 590-599 020-070, 072-099 605-609 100-109 613-618 118, 128, 138, 148, 158 620, 622-623, 625-629 161-163, 165-166, 168 639 173-174, 176-178 640-649 186-188 658 190-199 660-669 205, 215-218, 225-228 236-238, 241-248 680-689 254-255 690-699 262-268 701-718 276 725-728 281-288 733-738 294-298 741-748 308 751-758 313, 315-318 765-768 322, 333,334 770-779 335-338 780-789 343-348 791-798 353-358 800-809 363-366, 368 815-818

April 13, 2011 68


REVENUE CODE INVALID (continued) 372-373, 375-378 826-828 388 835-838 393-398 846-848 404-408 856-858

411, 414-418 860-869 425-428 870-879 435-438 882-888 445-448 890-898 451-455, 457, 458 904-908 461-468 913 473-478 926-928 484-488 930-939 491-498 948 501-508 950-959 513-518 960-989 524-528 532-538, 547-548 553-558, 563-568 573-578, 583-588

REVREQ

Issued when Provider General Type 18 does not have at least one of the following rev codes: 821 831 841 851 634 635

REV CODE MISSING OR INVALID FOR TYPE BIL (REVCDINV) 1. At least one Revenue Code must be present and equal to 3 or 4

numeric positions. Validate revenue code based on If Inpatient Bill Type, Revenue Code must be included in Valid Inpatient Bill Type

2. If Outpatient Bill Type, Revenue Code must be included in Valid Outpatient Bill Type

REV CODE REQ'S HCPCS CODE (HCPCSREQ)

If this is an outpatient type of bill, a revenue code requires a HCPCS code to be present.

April 13, 2011 69


REV CODE REQS LINE ITEM DATE OF SERVICE (CONT_REV)

If an outpatient claim contains an HMO, POS, or FEP POS contract and one of the following Revenue Codes is submitted:

0330, 0331, 0333, 0335, 0339, 0340 - 0342, 0349, 0420 - 0429, 0430-0439, 0440 - 0449, 0551, 0610 - 0619, 0900 - 0902, 0909 - 0910,0912 - 0916, or 0943, then the line item date of service must be present and on or within the Statement Covered From and Thru Dates.

REV CODE REQS SURGERY HCPCS (SGYHCPCS) If this is an outpatient type bill and a surgery revenue code is present, then a valid surgical HCPCS is required.

SEND CLAIM TO HOME PLAN

This claim must be filed directly with the Home Plan indicated on the subscriber’s ID card.

SEX Must be present. Valid codes are M or F.

SGYREV

Surgery revenue code not present on surgery: A surgery CPT4 code is present with a non-surgery revenue code. Revenue code must be 360-369, 480, 481, 490, 499, 750, or 759.

SOURCE OF ADMISSION INVALID (SRCADMIV)

Admission source must be completed if contract is out of state (out-of-area). Valid admission source codes are 1-9

SPAN CODE INVALID

The span code must be blank on BCBSLA inpatient claims. SPLIT BILL BY DATE OF SERVICE

This contact requires that the revenue codes indicated must be split by date of service or a specific date of service is required for each.

STATE

1. Must be present if billing an out of state (out of area) claim 2. Must be present if benefits are not assigned to your facility (assigned field

contains N) 3. Must be alpha

STATP#

This provider number is not allowed to submit interim bills. This provider number must submit all charges on one claim using the type of bill 111 and discharge status cannot be 30.

April 13, 2011 70


SUBSTANCE ABUSE PROV NUMBER MUST BE USED(SUBABUSE)

If this is an inpatient claim and the first three positions of the principal diagnosis code are equal to 291, 292, 303, 304, or 305, the claim must be filed with the BCBSLA provider number assigned for substance abuse claims.

SUPP CONT# FILE ON SUPP SCREEN You have entered a BCBSLA supplemental contract number. Your claim should crossover from the Medicare intermediary. If your claim does not automatically crossover from Medicare, you must file a hardcopy (paper) of the claim directly to BCBSLA for processing.

TOB INV WITH PATIENT STATUS

Type bill vs. status 1. If type bill is 112 or 113 then discharge status code must be 30 2. If type bill is 114 then discharge status cannot be 30.

TOTAL CHARGE MISSING OR INCORRECT (TOTAL001)

1. The total charge amount must be numeric 2. The total charge amount must be greater than zero 3. The total charge cannot be equal to zero 4. The total charge amount must be equal to the total charges for all the

revenue codes entered 5. Must use revenue code 001 for total 6. If revenue code 070 is present, this charge must be subtracted from the

total 001 Remove unless legacy still uses

TOTAL CHARGE = ZEROES Revenue code 001 must be greater than zero.

TOTCHG CANNOT EXCEED $999,999.99

Total charges cannot be greater than $999,999.99 on one claim. If you are not an FMP provider, you should split these charges and file two separate electronic claims. FMP providers must mail the complete UB04 for processing. Submit this claim hardcopy to BCBSLA.

TOTCHG ON NASCO EXCEEDS 99,999.99

NASCO claims with total charges greater than $99,999.99 must be mailed to BCBSLA for processing.

April 13, 2011 71


TYBL Type Bill - Inpatient

Must be 3 numeric positions 1. 1ST position must be 1 or 8 2. 2ND position must be 1, 2, or 3 3. 3RD position must be 1, 2, 3, 4, 7, or 8 4. 3RD position cannot be 2, 3, or 4 if provider participates in the

Fair Market Pricing Program.

Type Bill - Outpatient Must be 3 numeric positions

1. 1ST positions must be 1 or 8 (special facility) 2. 2ND position must be 3, or if 1ST position is 8, 2ND position

must be 2 or 3 3. 3RD position must be 1, 7, or 8 4. If 7 or 8 in 3RD position, must be submitting and adjustment

claim. TYPE OF ADMISSION INVALID

Admission type must be completed if contract is out of state (out-of-area). TYPE OF ADMISSION INVALID (ADMTYP)

Type of admission is a required field for facility claims. The type of admission may not be blank and must be equal 1, 2, 3, 4, 5 or 9

TYPE OF BILL INVALID (TYPBLINV)

Type bill – Inpatient 1. Must be 3 numeric positions 2. 1st position must be 1 or 8 3. 2nd position must be 1, 2, or 3 4. 3rd position must be 1, 2, 3, 4, 5, 7, or 8 5. 3rd position cannot be 2, 3, or 4 if provider participates in Fair

Market Pricing program

Type bill - Outpatient 1. Must be 3 numeric positions 2. 1st position must be 1 or 8 (special facility) 3. 2nd position must be 3, or if 1st position is 8, 2nd position must be

2 or 3 4. 3rd position must be 1, 5, 7 or 8 5. If 7 or 8 in 3rd position, must be submitting an adjustment claim

UNITRT

Unit’s times the rate must equal the charges.

April 13, 2011 72


UNITS1 Units must equal 1 for revenue code 45X.

UNIT10

Issued when units for the rev code 634 or 635 are less than 10 UNITS REQUIRED FOR REVENUE CODE (UNITSREQ)

Units must be present on all revenue codes and cannot be equal to zero. VALAMT

Value Amount 1. If a value code is present, then a value amount is required. 2. For inpatient billing, if value code 45 is present, then value amount

must equal 0100-2300, or 9900 3. For outpatient billing, if value code 45 is present, then value amount

must equal 0000-2300 or 9900

VALAMT AA > THEN COV DAYS ALLOWED Value Amount

1. For inpatient claims, the value amount is required and cannot exceed $2.00 per day for each Cov Day (FL 7).

2. For outpatient claims, value amount cannot exceed $1.00 VALUE CODE AA LA MANDATED SERV CHG INVAL (LAMANINV)

Revenue 071 or Value Code 'AA', 'BA', or 'CA' (Louisiana Mandated Service Charge) can only be present if:

1. Claim is not FEP (Contract Number begins with 'R' followed by eight or nine numeric characters)

2. Claim is inpatient or claim is outpatient and contains surgery CPT codes or diagnosis code V64.1 - V64.3

3. If the above criteria is met, the charge field related to 071 or the value amount related to 'AA', 'BA', or 'CA; must be $1 for outpatient Claims or ($2 times covered days) for inpatient claims

4. During the verification of the charge amount, all dollars associated with revenue code 071 and Value Codes 'AA', 'BA' or 'CA' should be used.

VCACHR Value code accident hour

1. If occurrence code 01-05 is present, then value code 45 (accident hour) and hour accident occurred is required.

2. To indicate the accident hour, use codes for admit hour followed by two zeros. Example: Accident hour 5:45 pm use 1700

April 13, 2011 73


VLCBLD Value code blood furnished

If revenue code 380, 381, or 382 is present, value code 37 (pints of blood furnished) and value amount is required. Value amount must be numeric and equal to the sum of units for blood revenue codes.

ZIP

1. Must be present if contract is out of state (out of area) 2. Must be present if benefits are not assigned to your facility

April 13, 2011 74


April 13, 2011 75

NPI EDITS BILLING NPI MATCHES MULTI PROVIDER RECORDS (BILNPIMU)

The Billing (pay provider) NPI on the claim is found in the BCBSLA system, but the NPI crosswalk to the BCBSLA Legacy numbers finds multiple providers that crosswalk back to this NPI.

BILL NPI NOT IN BCSYS FAXTO: 225-297-2750 (NONPIBIL)

The billing (pay provider) NPI on the claim is not set up or found in the BCBSLA system. Provider should contact the BCBSLA Provider Credentialing area to have their NPI number set up at 1-800-716-2299 before resubmitting claims.

BILLING NPI TAXID COMBO NOT SETUP FAX INFO (NPITXIN)

The billing NPI and tax combination cannot be found in the BCBSLA system.

BILLING PROVIDER TAXONOMY REQUIRED (TAXONBIL)

The billing (pay provider) NPI number information on the claim requires a taxonomy code to assist the system logic in finding a single Legacy provider number.

BILLING TAXONOMY CD NO SINGLE NPI MATCH (INVTXON)

The Billing (pay provider) NPI on the claim is found in the BCBSLA system, but the NPI crosswalk finds more than one provider number that crosswalks back to this NPI. A taxonomy code is present on the claim; however, that taxonomy code is not currently used in our logic and therefore a single provider number match cannot be found.

Documents

Blue Cross and Blue Shield of Louisiana Institutional 837I ... · Blue Cross and Blue Shield of Louisiana Institutional 837I Electronic Business Rules Guide April 13, 2011 3 I. Introduction