An independent licensee of the Blue Cross and Blue Shield Association. U7430a, 2/11

Mastering the basics to

prepare for the future

Institutional Services Session

+ Claims Overview

+ HIPAA 5010

+ Case Management

+ Network Management Reminders

+ Resources

+ Discussion

Topics for today

2

Claims Overview

+ Total 2010 Claim Volume: 42.2 Million

▪ Total Electronic Claim Volume: 38.8 million – 96%▪ Total Paper Claim Volume: 3.4 million – 4%

+ 87% Claims Processed within 7 Days:

+ Mailbacks:▪ 7% CMS-1500 Claims▪ 10% UB04 Claims

+ Provider Payments:▪ 52% are EFT payments representing 85% of monies paid▪ 48% of paper checks representing15% of monies paid

BCBSNC 2010 Claim Statistics:

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+ Top Denials for Claims:▪ Duplicate Denials

▪ Multiple Procedures

▪ Claims Outside Member Effective Date

▪ Other Insurance Primary

▪ No Authorizations

+ Adjusted Claim Reasons:▪ Corrected Claims

▪ Medicare COB Adjustments

▪ Benefit Package Changes / Incorrect Benefit Package Applied

▪ Commercial COB Adjustments

BCBSNC 2010 Claims Experience

5

The Basics of Claims Filing

6

Professional & Facility claims

must be submitted within 180

days of services being

rendered or the date of

discharge, with the exception

of claims for State and FEP

members.

Claims for FEP members must

be filed by December 31 of the

year after services were

rendered or date of discharge.

Claims for State PPO

members must be submitted

within 18-months of services

being rendered or the date of

discharge.

Claims Timely Filing Guidelines

+ BCBSNC encourages all hospitals, physicians and

health care professionals to submit claims

electronically.

+ Electronic claims filing allows faster, more efficient and

cost-effective claim submission for hospitals, physicians

and health care professionals.

+ The benefits of filing electronically include:▪ Reduction of overhead and administrative costs

▪ Receipt of reports are proof of claim receipt

▪ Faster transaction time for claims submitted electronically

▪ Validation of data elements on the claim

▪ Quicker claim completion

Electronic Claims Submission

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+ Member ID Number Errors▪ Professional: 32,801 claims were rejected representing $12.1

million in billed charges.

▪ Institutional: 2,963 claims were rejected representing $10.4 million in billed charges.

+ Security Errors – providers not set-up to submit claims

electronically or through a specific clearinghouse▪ Professional: 1,836 claims were rejected representing $1.2

million in billed charges.

▪ Institutional: 35 claims were rejected representing $183 thousand in billed charges.

+ Rendering NPI Errors - the rendering (performing)

physician’s NPI is not registered with BCBSNC –

professional only▪ Professional: 3,635 claims were rejected representing $1.2

million in billed charges.

Electronic Rejections – Week At A Glance

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Duplicate and Corrected Claims

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Duplicate Claims1st Quarter 2nd Quarter 3rd Quarter 4th Quarter

2011 2010 2011 2010 2011 2010 2011 2010

Total

Duplicates 81,847 68,382 96,903 80,337 - 65,171 - 68,864

Total Claims 881,325 865,955 940,491 901,102 - 853,605 - 872,157

Duplicates as

% of Claims 9.29% 7.90% 10.30% 8.92% - 7.63% - 7.90%

10.9% 10.6% 10.4%9.4% 9.7% 9.8%

10.6%11.2%

11.8%

16.0%

22.2%21.2%

11.7%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11

Duplicate Submission Rate by Month: Percent of Duplicates

+ A duplicate claim is any claim submitted by a

provider for the same service and same charge

amount provided to a particular individual on a

specified date of service that was included in a

previously submitted claim.

+ If you do not receive a response from your original

claim submission, please utilize available resources

prior to submitting a duplicate claim.

Duplicate Claim

+ Duplicate Claim Impacts:

▪ Processing Delays

– Additional Investigative Steps

▪ Unnecessary Denials

▪ Member Confusion

– Multiple EOBs

▪ Administrative Costs

– Member calls

– Resources required to research denials.

– Cost associated with resubmission.

+ A corrected claim is any claim that you have received an

NOP/EOP and need to make corrections from the original

submission.

+ Please remember the corrected claim replaces the original

claim; you must submit all charges that were on the original

claim rather than just the charge that has changed.

+ Providers using electronic data interchange (EDI) can submit

“institutional” corrected claims electronically rather than via

paper to BCBSNC.

+ Providers have 3-years from adjudication date to file a

corrected claim.

Corrected Claims

Claims Filing Tips

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+ Be sure to include patient’s correct alpha prefix.▪ FEP starts with an “R”

+ Claims should be typed and not hand-written.

+ Please do not highlight data on a claim, EOB, and any

other documentation that is submitted.

+ Ensure all required and conditional data elements are

populated on the UB04 claims form.

+ Use the most current and appropriate CPT and ICD-9

codes, when submitting claims to BCBSNC.

Claims Filing Tips

+ Allow sufficient time for Medicare primary claims to

crossover from Medicare.

+ Verify and submit all COB information.

+ Avoid filing new claims as corrected claims.

+ Avoid submitting paper claims.

+ Ensure your NPI numbers are register and linked

appropriately.

+ Submit requested medical records timely.

Tips to help prevent claim processing delays

HIPAA 5010

Mastering the Basics

+ An ERRATA (addenda) was approved at the end of

2010 that defined new versions for the 270/271, 837I,

837P, and 835 transactions.

+ Our 5010 migration updates and revised time lines:

5010 Trading Partner Migration

Transaction BCBSNC Migration Timeline

270/271 Eligibility Inquiry/Response July – December

276/277 Claim Status Inquiry/Response August – December

278 Authorization Request/Response July (late) – December

837 Institutional Claim Submission Sept – December

837 Professional Claim Submission Sept – December

835 Electronic Remittance Advice July (late) - December

999 Acknowledgement July through 2011

+ Complete the Migration Request Form ▪ www.bcbsnc.com/content/providers/edi/hipaainfo/agreements.htm

+ eSolutions analyst contacts trading partner

+ Test each transaction type in test environment

+ After passing compliance testing, eSolutions migrates the

vendor to 5010 versions

+ Note: ▪ BCBSNC will accept both 4010 and 5010 versions of all transactions

for the remainder of 2011.

▪ Once a vendor migrates to the 5010 version of 835, the 4010 is no longer sent.

▪ As of October 1st, no requests for 4010 set-ups will be accepted..

Migrating to Version 5010: Process for

Trading Partners

20

Case Management

Mastering the Basics

Case Management - An Advocate for Your

Patient’s Health

CASE MANAGER

Ensures Patients Understand

• Health status

• Treatment options and

implications

• Importance of treatment

• Available resources

• Information to share with

health care professionals

Patient reaches health

goals more efficiently

and effectively…

More effective

self-management

Avoidance of health-

related complications

and care expenses

Improved health status

Member

Turning Complex Health Issues into Health

OpportunitiesGuide Patient on Impacting

Their Overall Medical and

Psychosocial SituationComprehensive

Member

Assessment

Individualized Plan

Health Needs

Health Goals

Health Resources

Nurses

Dietitians

Pharmacist

Behavioral Health

Customer Service

Complex Health Issues

High Consumer of

Service

Gaps in Care

Case Management

Opportunities

Care Givers

CASE MANAGER

ACTIONABLE

IMPACTFUL

Targeting and guiding members to

improved self-management of their

health.

Social Workers

Physician/PCMH*

* Patient Centered Medical Home

Social Workers

Medical Home Collaboration

• BCBSNC’s Care Management and

Medical Home (MH) Collaboration

Program ensures effective

communications with physicians and

improved health outcomes through

increased case management

engagement.

• Case Managers become an

extension of the physician practice

focusing on member’s health and

care gap closure and providing

ongoing, consistent communication.

Decreased medical

expense

Decrease in utilization

Increase in appropriate

utilization

Case Management and

Blue Medicare Members

+ Patients that have:

▪ History of ER visits, hospitalizations and re-admissions for chronic conditions (e.g. CVA, CAD, fibromyalgia).

▪ New diagnosis of, or poorly controlled CHF, COPD, diabetes.

▪ Lack of knowledge regarding health condition and how to self-manage.

▪ Presence of multiple co-morbidities that complicate the primary chronic condition.

▪ Social isolation or other barriers, making it difficult for the patient to follow the physician’s recommended treatment plan.

Network Management Reminders

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+ BCBSNC has modified its billing and claims

submission policies and reimbursement policies and

have added a new medical policy effective 10/1/2011

that reduces the allowed amount for the technical

component of certain outpatient (hospital or provider

office) radiology procedures when performed in the

same session.

+ This updated medical policy is available at:

https://www.bcbsnc.com/assets/services/public/pdfs/

medicalpolicy/radiology_services_reimbursement_gui

delines_notification.pdf.

Multiple Radiology Procedure Payment

Reduction

+ BCBSNC will reimburse discarded drugs or biologicals

up to the dosage amount indicated on the vial or

package label minus the administered dose(s) if:

▪ The drug or biological is supplied in a single‐use vial or single‐use package;

▪ The drug or biological is initially administered to the patient to appropriately address the patient’s condition and any unused portion is discarded. A provider cannot bill BCBSNC for discarded drugs if none of the drug was initially administered to a patient (e.g. BCBSNC beneficiary misses an appointment).

▪ The amount wasted is recorded in the patient chart or a separate waste report log;

▪ The provider’s written policy and practice is to manage single-use drugs and biologicals and bill all payers in the same manner; and

▪ The amount billed to BCBSNC as discarded drug is not administered to another patient.

Drug Wastage

+ Modifier JW is defined as “drug or biological amount

discarded/not administered to any patient.”

Physicians, hospitals and other providers or suppliers

may use modifier JW to indicate drug wastage for

non-inpatient administered drugs.

+ BCBSNC requests providers report the drug amount

administered on one line, and on a separate line

report the amount of drug NOT administered

(wasted) with modifier -JW appended to the

associated HCPCS code.

JW Modifier

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Billing Reminders for Drug Wastage

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Do’s Don’ts

Do bill BCBSNC for discarded drugs and

biologicals up to the amount on the single-

use vial or package label minus the

administered dose(s) when appropriate.

Do not bill BCBSNC the extra amount the

drug manufacturer provided to account for

wastage in syringe hubs. Many

manufacturers provide an extra drug in each

vial to account for the wastage in the

syringe hubs. This extra amount should not

be billed to BCBSNC because it is not an

expense to the provider and it exceeds the

amount on the vial or package label.

Do use modifier JW when single‐use vials or

single use packages are appropriately

discarded after administering a dose(s). The

use of modifier JW is appropriate for

services rendered in all non-inpatient places

of service.

Do not bill BCBSNC for drug wastage if

none of the drug was initially administered.

BCBSNC will not reimburse for unused

drugs or biologicals that result from a

missed patient appointment.

Do not bill BCBSNC for discarded drugs or

biologicals for multi‐use vials.

+ Effective January 18, 2011, BCBSNC updated the

corporate medical policy on Hospital Acquired Conditions

and Never Events to provide more detailed explanation

on the conditions and codes.▪ This will allow us to better align BCBSNC policies and

procedures with CMS guidelines and to meet BCBS Association mandates around uniform handling of claims.

+ The revised corporate medical policy can be viewed at

http://www.bcbsnc.com/assets/services/public/pdfs/medi

calpolicy/nonpayment_for_serious_adverse_events.pdf.

Never Events and Hospital Acquired

Conditions

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+ Medicare Advantage claims fax line (336-659-2962) is

being removed from service on August 15, 2011.

+ New claims should be submitted electronically or via

mail to the appropriate address listed in the Provider

eManual.

+ Corrected claims should be submitted electronically

(utilizing the appropriate bill type and frequency code

per filing guidelines) or via mail.

+ Provider inquiries should be submitted by mail to

BCBSNC, PO Box 17509, Winston Salem, NC 27116-

7509.

Medicare Advantage Claims Fax Line

Removed from Service

Resources

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+ Members believed to have

other coverage should be

given a copy of the COB

questionnaire for completion.▪ Once completed, the member will

mail it to their Home Plan

+ This form is available for

download at:

http://www.bcbsnc.com/assets

/common/pdfs/BCBSNCCOBq

uestion.pdf.

IPP Coordination of Benefits Form

Spanish speaking patients

Web site:

www.bcbsnc.com/azul/

Spanish-speaking customer service

1-877-258-3334

Are you interested in

attending an in-depth

Provider Training

session?

If so, contact your

Provider Relations

Representative for details

on attending a session

located near you!

We’re serious about health care reform. Here’s how to make it work.

Available on the Web

Online resources –

bcbsnc.com/providers/

Blue e

Discussion

Best Practices

Thank you!