Name of Manual - Blue Cross and Blue Shield of Minnesota

Blue Cross and Blue
Shield of Minnesota
Provider Policy &
Procedure Manual
2012

CPT codes copyright 2012 American Medical Association. All Rights Reserved. CPT is a trademark of the AMA.

Recent Chapter changes:
Chapter 11
Durable Medical Equipment
Chapter 1 – At Your Service
Date Topic Changes
Chapter 2 – Provider Agreements
Date Topic Changes
Summary of Changes (2012)
Chapter 3 – Health Care Improvement
Date Topic Changes
Chapter 4 – Care Management
Type of Change(s)
Content New Topic Deletions Topic Deleted
Type of Change(s)
Content New Topic Deletions Topic Deleted
Type of Change(s)
Content New Topic Deletions Topic Deleted
Type of Change(s)
Date Topic Changes
Content New Topic Deletions Topic Deleted
1/31 Updated the language to this section in connection with annual
review of policies and procedures.
X
06/20 Medical Policy and Behavioral Health Policy Manual X
Chapter 5 – Health Care Options
Date Topic Changes
Chapter 6 – Blue Plus
Type of Change(s)
Content New Topic Deletions Topic Deleted
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/15/12) 1

Summary of Changes (2012)
Date Topic Changes
Chapter 7 – BlueCard
Date Topic Changes
Chapter 8 – Claims Filing
Date Topic Changes
Type of Change(s)
Content New Topic Deletions Topic Deleted
Type of Change(s)
Content New Topic Deletions Topic Deleted
Type of Change(s)
Content New Topic Deletions Topic Deleted
2/21 CMS 1500 Claim form information removed X
2/21 Exceptions revised X
05/10 Single facility claim submission X
Chapter 9 – Reimbursement/Reconciliation
Date Topic Changes
Chapter 10 – Appeals
Date Topic Changes
06/20 Utilization Review Decision Appeal X
Type of Change(s)
Content New Topic Deletions Topic Deleted
Type of Change(s)
Content New Topic Deletions Topic Deleted
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/15/12) 2

Chapter 11 – Coding Policies and Guidelines
Coding
Date Topic Changes
1/04 Reimbursement of HCPCS Codes, Page 11-2 x
06/20 CPT / Level I
Coding Immunizations and Injections
07/12 Preventive Care Services X
07/12 General Guides X
08/15 Durable Medical Equipment X
Copays
Date Topic Changes
Modifiers
Date Topic Changes
Anesthesia
Date Topic Changes
Type of Change(s)
Content New Topic Deletions Topic Deleted
X
Type of Change(s)
Content New Topic Deletions Topic Deleted
Type of Change(s)
Content New Topic Deletions Topic Deleted
Type of Change(s)
Content New Topic Deletions Topic Deleted
2/21 HICF 1500 References Deleted, Page 2 X
2/21 Qualifying Circumstances, Page 3 X
2/21 Epidural Anesthesia, Page 5 X
2/21 837P Added X
3 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/15/12)

Summary of Changes (2012)
Behavioral Health
Date Topic Changes
06/20 Coding Restrictions X
06/20 MHCP screening requirements X
06/20 Intensive Residential Treatment Services (IRTS) changed to
(Medicaid Government Programs Only)
Chiropractic
Date Topic Changes
Type of Change(s)
Content New Topic Deletions Topic Deleted
X
Type of Change(s)
Content New Topic Deletions Topic Deleted
3/6 Effective Date Removed from MHCP Requirements, Page 10 X
Dental Services
Date Topic Changes
3/6 Electronic Claim Format, Page 3 X
Durable Medical Equipment
Date Topic Changes
01/17 Medicare Advantage DME Rental Guidelines
Waiver Claim Submission
Coding Modifiers
DME Repairs and Maintenance (Excluding Oxygen
Equipment)
Billing for Supplies
Type of Change(s)
Content New Topic Deletions Topic Deleted
Type of Change(s)
Content New Topic Deletions Topic Deleted
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/15/12) 4
X

Durable Medical Equipment
Date Topic Changes
03/23 New section/policy re: Enrollment Requirements when Providing
Services to MHCP Members
Prior authorization: delete "durable medical equipment"
DME rental guidelines: large volume air compressors removed
Sample waiver form: delete "durable medical equipment"
Portable oxygen billing those added, these deleted
Coding modifiers: revisions to the LL, RR, NR definitions
DME repairs and maintenance (excluding oxygen equipment: add
DME, delete "durable medical equipment"
Billing for supplies: added "only" to first paragraph; corrected units
reporting location; removed references (1500 hicf) claim form
Pharmacies submitting DME Claims: delete "durable medical
equipment" change to DME
06/20 DME Rental Guidelines X
Home Health, Home Infusion, Hospice
Date Topic Changes
3/6 PCA modifier information and requirements added, Page 8 X
3/6 Corrected and added coding to grid, Page 10 X
3/6 MHCP PA requirements added, Page 15 X
4/6 Prior Authorization Verbiage updates, Pages 11-2 and 11-14 x
06/20 Home Infusion X
Type of Change(s)
Content New Topic Deletions Topic Deleted
5 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/15/12)
X
Type of Change(s)
Content New Topic Deletions Topic
Deleted

Summary of Changes (2012)
Hospital Care
Date Topic Changes
01/17 Critical Care
Hospital Observation
SNF Billing for Blue Plus Government Program
Products
03/12 critical care: added information/instructions re: time increments
SNF billing for blue plus government program products (continued):
add an "X" to the SNF type of bill - s/b 02XX
added section/policy re: medical necessity vendor
06/20 Leave of Absence (LOA) or furlough days X
07/12 Home Health X
Laboratory
Date Topic Changes
01/17 Introduction
Standing Orders
Papanicolaou Smears
Repeat Lab Services
03/23 new section/policy for collection and handling of speciments for
PMAP and MinnesotaCare Members Only
Maternity
genetic testing modifiers: added "as appropriate"
new section/policy for Lab billed through the BlueCard Program
Date Topic Changes
01/17 Newborn Care
Reproduction Treatment
06/20 Delivery X
Type of Change(s)
Content New Topic Deletions Topic Deleted
X
X
Type of Change(s)
Content New Topic Deletions Topic Deleted
X
X
Type of Change(s)
Content New Topic Deletions Topic Deleted
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/15/12) 6
X

Medical Emergency
Date Topic Changes
01/17 Emergency Department Services
Extended/After-hours Clinics
03/23 extended/after-hours clinics: deleted "1500 HICF" and "UB-04 X
Medical Services
Date Topic Changes
06/20 Evaluation and Management (E/M)
Office or Other Outpatient and Initial Inpatient Consultations
Chemotherapy Administration
Immunizations
Infusion Therapy
Coding
Weight Management Care
Assessment Management Program for Fully Insured
Optometric Optical Services
Date Topic Changes
Pharmacy Services
Date Topic Changes
Public Services
Date Topic Changes
Type of Change(s)
Content New Topic Deletions Topic Deleted
X
Type of Change(s)
Content New Topic Deletions Topic Deleted
X
Type of Change(s)
Content New Topic Deletions Topic Deleted
Type of Change(s)
Content New Topic Deletions Topic Deleted
Type of Change(s)
Content New Topic Deletions Topic Deleted
7 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/15/12)

Summary of Changes (2012)
Public Programs
Date Topic Changes
Radiology Services
Date Topic Changes
01/17 Comparison X-ray X
3/6 HTDI program information added, Pages 5-7 X
Type of Change(s)
Content New Topic Deletions Topic Deleted
Type of Change(s)
Content New Topic Deletions Topic Deleted
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/15/12) 8

Rehabilitative Services
Date Topic Changes
01/17 Physical Therapy Procedures
Physical Therapy Evaluation Codes
Occupational Therapy Evaluation Codes
Massage and Manual Therapy Exclusion
Massage and Manual Therapy Exclusion
Speech Therapy and Evaluation
01/17 Hot and Cold Pack Exclusion
MHCP PT, OT, ST Authorization Process
03/23 physical therapy evaluation codes: revised guidelines re: submission
of 97001-97002 with an E/M
occupational therapy: deleted "4" - CPT is no longer referred to as
CPT-4. It is only CPT
occupational therapy continued: remove dash between codes 97750
and 97755 and comma added. This is not a range of codes - there
are only these two codes.
occupational therapy evaluation codes: revised guidelines re:
submission of 97003-97004 with an E/M
mhcp pt, ot, st authorization process: deleted effective date
reference; group numbers added to affected programs
mhcp pt, ot, st authorization process continued: effective date and
information re; specialized maintenance therapy
added section and policy for "medical necessity vendor"
Type of Change(s)
Content New Topic Deletions Topic Deleted
9 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/15/12)
X
X
X

Summary of Changes (2012)
Surgical Services
Date Topic Changes
02/22 General Guidelines X
02/22 Global Surgical Package X
02/22 Fractures X
02/22 Stand-by Services X
03/23 Lesions: corrected code range
Correct billing of Q1003 for Medicare advantage products: deleted
section - code no longer valid
Acne treatment/skin rejuvenation and rosacea treatment: deleted
"and Blue Shield of Minnesota and Blue Plus"
Intra-articular hyaluronan injections for osteoarthritis: deleted "and
Blue Shield of Minnesota and Blue Plus"
Assistant surgeons: added "or clinical nurse specialist"
Multiple surgeries: corrected payment information - "billed" and
"charge" deleted; "highest allowed" and "allowed" added
Type of Change(s)
Content New Topic Deletions Topic Deleted
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/15/12) 10
X

Table of Contents
Chapter 1
At Your Service
Introduction................................................................................................................................ 1-3
Provider Policy and Procedure Manual ................................................................................. 1-3
Blue Cross and Blue Shield Plans..........................................................................................1-3
Blue Plus ................................................................................................................................ 1-3
CPT Copyright.....................................................................................................................1-4
How to Contact Us ..................................................................................................................... 1-5
Provider Services ...................................................................................................................1-5
Federal Employee Program.................................................................................................... 1-5
Calls Not Handled by Provider Services ............................................................................... 1-5
Behavioral Health Service Numbers...................................................................................... 1-6
BlueCard ® Benefits and Eligibility........................................................................................1-6
Provider Claim Adjustment / Status Check ...........................................................................1-6
General Address.....................................................................................................................1-6
Claims Address ......................................................................................................................1-7
Care Management Numbers and Addresses ..........................................................................1-7
Other Numbers and Addresses............................................................................................. 1-12
Address Changes and Other Demographic Information......................................................1-13
BLUELINE............................................................................................................................... 1-14
Introduction..........................................................................................................................1-14
BLUELINE Availability...................................................................................................... 1-14
Calling BLUELINE .............................................................................................................1-14
System Assistance................................................................................................................ 1-14
Provider Identification .........................................................................................................1-15
Member Identification ......................................................................................................... 1-15
Date...................................................................................................................................... 1-15
Provider Web Self-Service ...................................................................................................... 1-16
ID Cards.................................................................................................................................... 1-17
Introduction..........................................................................................................................1-17
ID Cards...............................................................................................................................1-17
Helpful Tips .........................................................................................................................1-18
Blue Cross Blue Shield of Minnesota Provider Policy and Procedure Manual (10/24/11) 1-1

At Your Service
Electronic Commerce .............................................................................................................. 1-19
Overview..............................................................................................................................1-19
Electronic Transactions........................................................................................................1-19
Electronic Data Interchange (EDI) Guidelines.................................................................... 1-19
Remote Access Services ...................................................................................................... 1-20
Provider Communications ...................................................................................................... 1-23
Member Rights and Responsibilities...................................................................................... 1-24
Health Plan Members have the Following Rights ...............................................................1-24
Health Plan Members have the Following Responsibilities ................................................1-25
1-2 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (10/24/11)

Introduction
Provider Policy and
Procedure Manual
Blue Cross and
Blue Shield Plans
At Your Service
Blue Cross and Blue Shield of Minnesota developed the Provider
Policy and Procedure Manual for participating health care
providers and your business office staff. This manual provides
information about our claims filing procedures, payments, provider
agreements, managed care requirements, communications and
other topics that affect patient accounts and patient relations. As
policies and procedures change or clarification is needed, Blue
Cross will keep you updated through Provider Bulletins, Quick
Points and the Provider Press, found at bluecrossmn.com.
Information in this manual is a general outline and is part of your
provider contract. Provider and member contracts determine
benefits.
Blue Shield plans for professional services began to form across
the nation in the 1940s, after the successful Blue Cross movement
of the 1930s was well underway. Today, there are many Blue
Cross and Blue Shield Plans throughout the United States. Blue
Cross and Blue Shield Plans may be separate companies or
combined as one company. Each plan is an independent business
organization and a nonprofit independent licensee of the Blue
Cross and Blue Shield Association.
The Blue Cross and Blue Shield Association, headquartered in
Chicago, is an association of independent Blue Cross and Blue
Shield Plans. It sets performance standards and bids for national
contracts and programs. It also organizes advertising campaigns,
conducts research and coordinates legislative efforts on behalf of
the association’s members.
Blue Plus Blue Plus, an affiliate of Blue Cross, is a state-certified health
maintenance organization (HMO). In most Blue Plus products,
members select a participating primary care clinic that coordinates
all of the patient’s medical care and authorizes treatment by
specialists when necessary.
Because Blue Plus is an affiliate of Blue Cross, Blue Plus is
subject to most of the same policies and procedures. For general
information about Blue Plus, you may refer to Chapter 6 of this
manual. Blue Plus primary care clinics should refer to the Blue
Plus Provider Manual for specific Blue Plus guidelines. Blue Plus
is a nonprofit independent licensee of the Blue Cross and Blue
Shield Association.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (10/24/11) 1-3

At Your Service
CPT Copyright CPT codes copyright 2010 American Medical Association. All
Rights Reserved. CPT is a trademark of the AMA. No fee
schedules, basic units, relative values or related listings are
included in CPT. The AMA assumes no liability for the data
contained herein. Applicable FARS/DFARS restrictions apply to
government use.
1-4 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (10/24/11)

How to Contact Us
At Your Service
Provider Services A conversation with one of our service representatives often can
solve a problem immediately or give you an answer to a claims
question. The representatives answering the provider services
numbers are available to assist you:
Federal Employee
Program
Calls Not Handled by
Provider Services
Monday – Thursday ..........8 a.m. – 5 p.m.
Friday ................................9 a.m. – 5 p.m.
In an industry that is constantly changing, ongoing education of
our provider services representatives is necessary. To meet this
challenge, Blue Cross conducts staff training every Friday morning
from 8 a.m. – 9 a.m.
Please have your provider number or NPI and if applicable, the
member’s identification number, account number and claim
number ready when you call. The provider services telephone
numbers listed are for the provider’s use only. Please refer
members to the customer service telephone number on the back of
their member identification (ID) card.
The general provider services phone numbers are (651) 662-5200
(Twin Cities area) and 1-800-262-0820 (toll free). Listen for the
current phone options when you call.
The general provider services fax number is (651) 662-2745.
Providers who are calling to check eligibility and benefits for
Federal Employee Program members can utilize the voice response
unit specific to FEP.
Claim status is not available at this time. Providers will be
prompted to speak to a service representative for all FEP claims
questions. To access this service, call (651) 662-5044 or
1-800-859-2128. FEP members are recognized by an “R” followed
by eight numeric digits in their identification number.
Calls for the accounts on the next page are not handled by provider
services. Please use the phone numbers listed. In addition, calls
from independent social workers who are working as patient
advocates should call the customer service phone number on the
back of the member’s ID card.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (10/24/11) 1-5

At Your Service
Calls Not Handled by
Provider Services
(continued) Accounts and how to ID them Phone Numbers
TRICARE/TRIWEST
Behavioral Health
Service Numbers
BlueCard ® Benefits and
Eligibility
Provider Claim
Adjustment / Status
Check
Federal Employee Program
ID number starts with an R
General Address The general address is:
(651) 662-5044
1-800-859-2128
Behavioral health customer service ................Call the number on
the member’s card, or call 1-888-874-9378, local (651) 662-3484.
Inpatient mental health fax..............................(651) 662-0856
Outpatient mental health fax ...........................(651) 662-0854
Inpatient chemical dependency fax.................(651) 662-0856
Outpatient chemical dependency fax ..............(651) 662-0854
Pre-certification: fax to the numbers listed above.
To verify benefits or eligibility for BlueCard members, call
1-800-676-BLUE (2583). Refer to Chapter 7 for additional
information.
The Provider Claim Adjustment / Status Check Form is
designed for providers to fax or mail their inquiries to Blue Cross.
The applicable FAX number is listed on the form or mail it to the
general Blue Cross address (see below).
All the fields are required to be completed, if applicable. Make
sure to clearly state the contact name, phone number and contact's
FAX number.
The inquiries can be an adjustment request or claim status request
for regular or BlueCard business.
The form will not be returned to you unless Blue Cross needs
clarification on your request. All adjustments that are completed
will be found on a future remittance advice.
A sample of the Provider Claim Adjustment / Status Check
Form can be found on our website, bluecrossmn.com.
Blue Cross and Blue Shield of Minnesota
P.O. Box 64560
St. Paul, MN 55164-0560
(Claims adjustment requests inquires should be mailed to this
address)
1-6 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (10/24/11)

At Your Service
Claims Address Submit claims electronically whenever possible. All Minnesota
and out-of-state participating providers are required to
electronically submit all claims according to Minnesota Statute
62J.536 and the participating provider contracts. Paper claims
submitted by Minnesota and out-of-state participating providers
will be rejected to be resubmitted electronically. Blue Cross will
not consider such paper claims to have been received until
resubmitted electronically. Nonparticipating out-of-state providers
may submit a scannable claim form to:
Care Management
Numbers and
Addresses
Blue Cross and Blue Shield of Minnesota Claims
P.O. Box 64338
St. Paul, MN 55164-0338
The phone numbers, fax numbers and addresses for care
management and utilization management are listed below.
Area
Phone/Fax Numbers
and Addresses
Case Management Non Government Programs
(651) 662-5520
FAX: (651) 662-1004
Government Programs Case
Management
(PMAP, MNCARE, MN
Senior Care Plus, MSHO –
SecureBlue SM , CareBlue SM )
(651) 662-5540 or
1-800-711-9868
FAX: (651) 662-6054 or
1-866-800-1665
Fraud Hot Line (651) 662-8363 or
1-800-382-2000
extension 28363
Preadmission Notification
(PAN)
Medical and behavioral health
inpatient admissions.
Preadmission notifications are
required to occur through
provider web self-service.
providerhub.com
(651) 662-5270 or
1-800-528-0934
Medical FAX:
(651) 662-6860
Behavioral Health FAX:
(651) 662-0856
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (10/24/11) 1-7

At Your Service
Care Management
Numbers and
Addresses (continued)
Area
Utilization Management
Prior authorization requests
(may be called or Faxed)
Home health services
Home infusion services
Hospice care
Skilled nursing facility
Admissions
Phone/Fax Numbers
and Addresses
Commercial Intake
(651) 662-5520 or
1-888-878-0139, x25520
FAX: (651) 662-1004
Utilization Management For all other UM inquiries,
contact provider services at
1-800-262-0820 or
(651) 662-5200 and they will
triage your call appropriately.
Government Programs
Prior authorization requests or
notifications
(may be called or faxed)
Home health care services
Home infusion services
PCA services
Skilled nursing/nursing
facility services (fax PMAP or
Nursing Facility
Communication Form)
County waivered services
Hospice services
All services from
nonparticipating providers
Case Management,
Government Programs
(651) 662-5540 or
1-800-711-9868
FAX: (651) 662-6054 or
1-866-800-1665
1-8 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (10/24/11)

Care Management
Numbers and
Addresses (continued)
Area
Medical Policy and Durable
Medical Equipment (DME)
Prior Authorization Requests
(must be faxed or mailed)
For commercial/nongovernment
programs
Cosmetic surgery
Dental/oral surgery-inpatient
Spinal cord stimulation
DME
Communication devices
DME over $1,000 without
an assigned HCPCS code
Electrical bone growth
stimulators
Gravity lumbar reduction
devices
Specialty beds/overlays
Vest percussor for cystic
fibrosis
Wheelchair (purchase
only)
Gastric bypass surgery
Growth hormone
Infertility service and drugs
Investigative procedure (refer
to Medical Policy Update on
website)
Weight-loss programs
Services recommended by
Medical Policy
Phone/Fax Numbers
and Addresses
FAX: (651) 662-2810
At Your Service
Address:
Blue Cross and Blue Shield of
Minnesota
Medical Review
R4-72
P.O. Box 64265
St. Paul, MN 55164-0265
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (10/24/11) 1-9

At Your Service
Care Management
Numbers and
Addresses (continued)
Area
Government Programs
(PMAP, MNCare, MN Senior
Care Plus, MSHO/SecureBlue,
CareBlue)
All of the above mentioned
services, in addition to the
following:
DME over $500 (SecureBlue)
Prosthetics over $1,000
(MSHO)
Wheelchair (rental and
purchase)
Cesarean section
Hysterectomy
Tympanostomy tubes
See website for complete list.
Behavioral Health Outpatient
Services
Prior Authorization
(must be mailed or faxed)
For inpatient services, refer to the
Preadmission Notification
section.
Chiropractic
Prior Authorization Requests
(must be faxed or mailed)
Phone/Fax Numbers
and Addresses
FAX: (651) 662-6054 or
1-888-800-1665
Address:
Blue Cross and Blue Shield of
Minnesota
Medical Review
R244
P.O. Box 64560
St. Paul, MN 55164
Outpatient Mental Health
and Outpatient Chemical
Dependency
FAX: (651) 662-0854
Address:
Blue Cross and Blue Shield of
Minnesota
Behavioral Health
P.O. Box 64265
St. Paul, MN 55164-0265
FAX: (651) 662-7816
Address:
Blue Cross and Blue Shield of
Minnesota
Allied Health Services
R4-72
P.O. Box 64265
St. Paul, MN 55164-0265
1-10 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (10/24/11)

Care Management
Numbers and
Addresses (continued)
Area
Medical Dental
Prior Authorization Requests
(may be faxed or mailed)
Surgical TMJ services
Orthognathic/osteotomies
Orthodontics for TMJ and
cleft lip/palate
Bone grafts
Bridges for accidental injuries
Anesthesia and
inpatient/outpatient hospital
charges for dental care
provided to a covered person
who is a child under age five
(5); is severely disabled or has
a medical condition that
requires hospitalization or
general anesthesia for dental
treatment.
PT/OT/ST
Prior Authorization Requests
(may be faxed or mailed)
Participating providers
(Refer to Chapter 4-Care
Management for details)
Transplants
Prior Authorization Requests
(may be mailed or phoned)
Phone/Fax Numbers
and Addresses
FAX: (651) 662-7816
At Your Service
Address:
Blue Cross and Blue Shield of
Minnesota
Medical-Dental Review
R4-72
P.O. Box 64265
St. Paul, MN 55164-0265
FAX: (651) 662-7816
Address:
Blue Cross and Blue Shield of
Minnesota
Allied Health Services
R4-72
P.O. Box 64265
St. Paul, MN 55164-0265
(651) 662-9936 or
1-866-309-6564
FAX: 651-662-1624
Address:
Blue Cross and Blue Shield of
Minnesota
P.O. Box 64179
Route R4-72
St. Paul, MN 55164-0265
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (10/24/11) 1-11

At Your Service
Care Management
Numbers and
Addresses (continued)
Other Numbers and
Addresses
Area
Phone/Fax Numbers
and Addresses
Referrals Provider web self-service:
www.providerhub.com
FAX: (651) 662-6860
These phone numbers, fax numbers and addresses may be helpful
to you.
Company Phone Number Address
Healthy Start ® Prenatal
Support
(651) 662-1818
1-866-489-6948
Healthy Start
P.O. Box 64060
St. Paul, MN 55164-0560
BlueLink TPA Refer to Member’s ID card BlueLink TPA
P.O. Box 64668
St. Paul, MN 55164
Delta Dental ® of
Minnesota
(651) 406-5900 or
1-800-328-1188
FAX: (651) 406-5934
MII Life Inc. (651) 662-5065
1-800-859-2144
Prime Therapeutics LLC (612) 777 -4000
or
1-800-858-0723
Pharmacy help desk:
1-800-821-4795
(for pharmacist or doctor use
only)
Customer Service Refer the member to their
customer service number printed
on the back of their member ID
card. They may also call
(651) 662-8000.
Medicare & More
Customer Service
Minnesota Health Care
Programs (through DHS)
Eligibility Verification
System (EVS)
(651) 662-5020 or
1-800-531-6686
(612) 282-5354 or
1-800-657-3613
Delta Dental of Minnesota
3560 Delta Dental Drive
Eagan, MN 55122
MII Life Inc.
3535 Blue Cross Road
P.O. Box 64193
St. Paul, MN 55164-9828
Prime Therapeutics
1305 Corporate Center Drive
Eagan, MN 55121
1-12 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (10/24/11)

Company Phone Number Address
Public Programs Member
Services (PMAP and
MinnesotaCare)
Address Changes and
Other Demographic
Information
(651) 662-5545 or
1-800-711-9862
At Your Service
Promptly notify Blue Cross when any of your demographic
information changes, including but not limited to your address,
phone number, hospital affiliation or office hours. Use the
Provider Demographic Change Form, available at
providers.bluecrossmn.com. Enter “provider demographic
change form” in the search window. Blue Cross uses your
demographic information in provider directories, to help members
find you easily, mail important information to you, etc. Call (651)
662-5200 or 1-800-262-0820 for telephonic assistance. FAX
completed forms to (651) 662-6684 or mail them to:
Blue Cross and Blue Shield of Minnesota
PDO, S116
P.O. Box 64560
St. Paul, MN 55164-0560
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (10/24/11) 1-13

At Your Service
BLUELINE
Introduction BLUELINE is a voice response system for our health care
providers. It furnishes immediate information regarding covered
Blue Cross members.
BLUELINE offers callers the following information:
Prior authorization
Member specific claim*
Member specific eligibility*
Member specific benefit*
Member specific primary care clinic
*A fax back of this information is available by following the menu
options within BLUELINE.
BLUELINE Availability BLUELINE is available 24 hours a day, seven days a week; except
during scheduled maintenance.
Calling BLUELINE You can access BLUELINE by calling (651) 662-5200 or
1-800-262-0820.
If the information you are requesting is not available within
BLUELINE, you will be automatically routed to a service
representative during normal service hours:
Monday-Thursday....8 a.m. – 8 p.m.
Friday 9 a.m. – 5 p.m.
System Assistance If you require assistance in accessing BLUELINE or have not
received your fax, call technical support at (651) 662-5555 or toll
free at 1-800-711-9871 and select option three. Blue Cross will
need the following information:
Provider number and name
Date and time of occurrence
Caller’s name and telephone number
Description of the problem
FAX number, if applicable.
1-14 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (10/24/11)

At Your Service
Provider Identification Provider identification is required for obtaining claim information
or requesting a FAX back of claim information for a specific
member.
BLUELINE will prompt you when necessary for your provider ID.
Your choices will be “Blue Cross Blue Shield of Minnesota
Provider ID,” “NPI” or “TAX ID.”
You may request any of these options just be speaking the words –
such as saying, “NPI.” BLUELINE will then prompt you for the
actual numbers for just that ID. Just speak naturally, one character
or number at a time.
Member Identification When BLUELINE prompts you for the member ID, just speak the
numeric portion or enter it using your touch-tone keypad. For
example, if the member ID is XZA XZ1234567, just speak or enter
1234567, one digit at a time.
Date When BLUELINE prompts you for the date of birth or date of
service, just say the date naturally, for example March 17, 1964 or
3-17-1964. You may also enter the date using your touch-tone
keypad. If using the keypad, enter all eight digits – i.e. 03171964.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (10/24/11) 1-15

At Your Service
Provider Web Self-Service
Provider Web
Self-Service
Provider web self-service is a web-based service available to
providers. This program allows you access to eligibility and
benefits, referrals, claim status and provider searches and
remittance advices.
The system is available 24 hours a day, seven days a week except
for scheduled maintenance times and the use of case functionality.
For support in the Twin Cities call (651) 662-5743 or toll free at
1-866-251-6743 or email support@providerhub.com.
For additional information, including an application, visit the
website at: providerhub.com.
1-16 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (10/24/11)

ID Cards
At Your Service
Introduction Your patient’s member ID card contains information that is
essential for claims processing. Blue Cross recommends that you
look at the patient’s ID card at every visit and have a current copy
of the front and back of the card on file. There is a sample of some
of the ID cards issued from Blue Cross on our website. Some of
the following information may be found on the ID card:
Name of the plan
Member’s ID number including alpha prefix
Member’s name and group number
Primary care clinic (PCC) name – for managed care plans only
Blue Shield plan code
Blue Cross plan code
Prescription coverage
Copay for prescription drugs
Copay for office visits
Dependent coverage indicator
Claims submission information
ID Cards Blue Cross and its affiliates do not use Social Security numbers for
member identification numbers
Members from the following Blue Cross line of business will
retain their original identification number:
Minnesota government programs
Prepaid Medical Assistance Program
MinnesotaCare (identification numbers begin with an eight).
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (10/24/11) 1-17

At Your Service
Helpful Tips Blue Cross plans have the option of creating identifiers with any
combination of up to 14 letters or digits following the three-digit
alpha prefix.
Verify the identity of Blue Cross and Blue Plus cardholders by
asking for additional picture identification. If you suspect
fraudulent use of a member ID card, please call our fraud hot
line at (651) 662-8363. You may remain anonymous.
Ask members for their current member ID card and regularly
obtain new photocopies (front and back). Having the current
card will enable you to submit claims with the appropriate
member information and avoid unnecessary claims payment
delays.
Check eligibility and benefits by using provider web selfservice,
BLUELINE, or call 1-800-676-BLUE (2583) and
provide the alpha prefix for BlueCard eligibility.
If the member presents a debit card be sure to verify the
copayment amount before processing payments.
Do not use the card to process full payment up front. If you
have questions about the debit card processing instructions or
payment issues, please contact the toll-free debit card
administrator’s number on the back of the card.
1-18 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (10/24/11)

Electronic Commerce
Overview An important part of Blue Cross’ cost containment strategy is
automating the electronic exchange of information.
At Your Service
Electronic Transactions Blue Cross accepts the submission and/or generates the following
HIPAA compliant transactions:
Electronic Data
Interchange (EDI)
Guidelines
Health Care Claim (837 P and D)
Health Care Claim Payment/Advice (835)
Health Care Eligibility Benefit Inquiry and Response
(270/271)
Health Care Claim Status Request and Response (276/277)
Health Care Services Review- Request for Review and
Response (278)
Blue Cross uses Availity for exchanging HIPAA mandated EDI
transactions. You can get information on how to register and
conduct electronic transactions through Availity by going to
Availity.com.
Minnesota Statute 62J.536 requires all Minnesota providers
and Minnesota group purchasers to exchange three transactions
electronically: Health Care Claims, Health Care Claim
Payment/Advice and Health Care Eligibility Benefit Inquiry
and Response. In addition, participating out-of-state providers
are required by contract to adhere to these electronic
requirements.
All nonparticipating, out-of-state providers who do not have
electronic claim submission capabilities must submit their
claims on an optical character recognition scannable claim
form.
All nonparticipating, out-of-state providers who are receiving
direct payment must access their remittance advice via use of
the electronic transaction or provider web self-service.
Blue Cross reserves the right to modify these guidelines with
advance written notice.
Providers are encouraged to obtain or develop EDI transaction
software from the many sources available.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (10/24/11) 1-19

At Your Service
Remote Access
Services
Providers may be permitted to use Blue Cross' remote access
services, allowing them to obtain specific subscriber information
and other information necessary for submitting claims and viewing
claim status or payment information. Access may not be
transferred to another entity by the provider and Blue Cross retains
all rights to the computer software system. Providers may only use
the system to:
verify health plan coverage benefits of their patients
verify claims status
verify cases (such as referrals and admission notifications)
create and update referrals (available only for primary care
clinics)
create and update admission notifications (available only to
primary care clinics and inpatient facilities)
for external security delegated administration
view remittance advice information
other purposes to be communicated by Blue Cross
Providers have certain responsibilities when using Blue Cross'
remote access services. They include:
Access is for the provider only, and third parties may not have
access to the system without advance written approval of Blue
Cross.
Blue Cross is the sole and exclusive owner of the system and
its components, and the provider does not have any rights to it,
either intellectual property rights or other rights of any kind.
The provider may not reverse assemble, decompile, duplicate
or modify the system or any parts of it.
At any time, Blue Cross may modify or enhance the system, or
replace the system with an entirely new system.
Provide all necessary components for using Blue Cross'
system, such as compatible software, hardware, access to the
Internet and any other necessary technology to access the
system.
Blue Cross may discontinue the provider's access to the system
or terminate use of the system upon thirty (30) days advance
written notice to the provider.
1-20 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (10/24/11)

Remote Access
Services
(continued)
At Your Service
Providers may access Blue Cross' system via the Internet (or other
technology as approved by Blue Cross) at any time, except when
the system is undergoing maintenance or repairs, or due to
interruptions beyond the control of Blue Cross. Providers are
solely responsible for the necessary software, hardware, access to
the Internet, and other technology or services necessary for
providers to use the system.
Only authorized users may access the system and use its services.
Authorized users are employees of the provider and others
included in the provider's workforce (in accordance with 45
C.F.R. 160.103).
The provider must designate authorized users and obtain access
through Blue Cross for them to use the system, either through a
user request form or directly entering into the system the
information required on the user request form.
Blue Cross will assign a user name upon acceptance of the user
request form.
Each individual user name and password and each Blue Cross
assigned user identification number/code and password is used
only by the respective authorized user and may not be shared
with anyone.
The provider must provide immediate written notification to
Blue Cross whenever an authorized user terminates
employment with the provider.
The provider must also notify Blue Cross of any other changes,
deletions and/or modifications to information originally
submitted on the user request form.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (10/24/11) 1-21

At Your Service
Remote Access
Services
(continued)
Disclaimer: provider’s use of the services and the system and any
information obtained there from is subject at all times to
instructions, notices and/or disclaimers appearing on-line on the
system from time to time.
The services and the system are provided “AS IS” and Blue
Cross makes no representation or warranty that the system will
meet provider’s requirements or that the system will operate
uninterrupted or error free, or that the information obtained is
or will be accurate.
Blue Cross makes no warranties of merchantability, fitness for
a particular purpose, non-infringement or otherwise, all of
which are expressly disclaimed.
Payment: Blue Cross reserves the right to require providers to pay
remote access service fees. In such an event, Blue Cross will
provide at least 90 days’ advance written notice to providers. Such
fees will be due and payable within 30 days of any invoice and late
payments will be subject to interest at a rate of the lesser of (a) one
and one-half percent per month or (b) the highest rate allowed by
law.
Limitation of Liability: Blue Cross’ entire liability to provider for
any and all damages incurred by provider for any and all claims
arising out of, or otherwise relating to remote access services
described above shall in the aggregate not exceed 100 percent of
the total remote access services fees received by Blue Cross. Blue
Cross will not be liable for any damages caused by provider’s
failure to perform its responsibilities and/or for any indirect,
special or punitive damages, even if Blue Cross has been advised
of or is otherwise aware of the possibility of such damages.
1-22 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (10/24/11)

Provider Communications
Provider
Communications
At Your Service
Blue Cross publishes the following communications for providers.
They are available on our website at providers.bluecrossmn.com.
Title Description
Provider Bulletins Blue Cross communicates immediate policy
and procedure changes through Provider
Bulletins. The Provider Bulletins are
contractually binding. Portions of this
manual will also be updated periodically to
reflect policy and procedure changes.
Provider Press The goal of this publication is to make your
job easier and to improve our service to you.
The categories that are featured in the
Provider Press include claims tips,
PMAP/MinnesotaCare, Coding Corner and a
featured front page article.
Provider
Information
Quick Points
Medical Policy
Update
Blue Plus Referral
Network for
Primary Care
Clinics
This is a communication tool that Blue Cross
is using to get helpful information to you.
Changes to Medical Policy impacting
payment are communicated through Provider
Bulletins. Blue Cross also includes updates in
the Provider Press on a quarterly basis. The
updates contain a summary of medical
technologies that have been reviewed,
revised, or are new to Blue Cross’
investigative list. Prior authorization request
requirements are also featured in this
publication.
This is a listing of specialty providers for
referral purposes.
Blue Plus Manual The Blue Plus Manual is published for our
Blue Plus primary care providers. It includes
information about the Blue Plus business,
referrals, contacts, quality improvement, and
government programs.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (10/24/11) 1-23

At Your Service
Member Rights and Responsibilities
Health Plan Members
have the Following
Rights
Blue Cross and Blue Shield of Minnesota
Enrollee Rights and Responsibilities
YOU HAVE THE RIGHT AS A HEALTH PLAN MEMBER:
To be treated with respect, dignity and privacy.
To receive quality health care that is friendly and timely.
To have available and accessible medically necessary covered
services, including emergency services, 24 hours a day, and
seven (7) days a week.
To be informed of your health problems and to receive
information regarding treatment alternatives and their risk in
order to make an informed choice regardless, if the health plan
pays for treatment.
To participate with your health care providers in decisions
about your treatment.
To give your provider a health care directive or a living will (a
list of instructions about health treatments to be carried out in
event of incapacity).
To refuse treatment.
To have privacy of medical and financial records maintained
by Blue Cross and its health care providers in accordance with
existing law.
To receive information about Blue Cross, its services, its
providers and your rights and responsibilities.
To make recommendations regarding these rights and
responsibilities policies.
To have a resource at Blue Cross or at the clinic that you can
contact with any concerns about services.
To file a complaint with Blue Cross and the Minnesota
Commissioner of Commerce and receive a prompt and fair
review.
To initiate a legal proceeding when experiencing a problem
with Blue Cross or its providers.
1-24 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (10/24/11)

Health Plan Members
have the Following
Responsibilities
At Your Service
YOU HAVE THE RESPONSIBILITY AS A HEALTH PLAN
MEMBER:
To know your health plan benefits and requirements.
To provide, to the extent possible, information that Blue Cross
and its providers need in order to care for you.
To understand your health problems and work with your doctor
to set mutually agreed-upon treatment goals.
To follow the treatment plan prescribed by your provider or
discuss with your provider why you are unable to follow the
treatment plan.
To provide proof of coverage when you receive services and to
update the clinic with any personal changes.
To pay copays at the time of service and to promptly pay
deductibles, coinsurance and if applicable, charges for services
that are not covered.
To keep appointments for care or to give early notice if you
need to cancel a scheduled appointment.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (10/24/11) 1-25

Table of Contents
Chapter 2
Provider Agreements
Participation and Responsibilities............................................................................................ 2-2
Advantages of Participation................................................................................................... 2-2
Responsibilities of Participating Providers............................................................................ 2-2
Requirements of Minnesota Law...........................................................................................2-4
Blue Cross' Responsibilities...................................................................................................2-5
Written Notification and Provider Liability...........................................................................2-5
Provider Numbers...................................................................................................................... 2-6
Overview................................................................................................................................2-6
National Provider Number (NPI)...........................................................................................2-6
Credentialing.............................................................................................................................. 2-7
Overview................................................................................................................................2-7
Credentialing Requirements and Processes ...........................................................................2-7
Questions about Credentialing............................................................................................... 2-7
Accounting for Disclosure Request .......................................................................................... 2-8
Guidelines for the Accounting Disclosure Request...............................................................2-8
When to Use the Form ...........................................................................................................2-8
Disclosures Related to Your Status as a Business Associate................................................. 2-9
Carrier Replacement Law....................................................................................................... 2-10
Carrier Replacement ............................................................................................................ 2-10
How Carrier Replacement Works........................................................................................2-10
Continuous Stay...................................................................................................................2-10
Public Programs...................................................................................................................2-11
Federal Employee Program..................................................................................................2-11
InstaCare SM ..........................................................................................................................2-11
Self-funded Groups and Minnesota Advantage Health Plan ............................................... 2-11
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (01/05/10) 2-1

Provider Agreements
Participation and Responsibilities
Advantages of
Participation
Responsibilities of
Participating Providers
Advantages of being a participating provider include:
• Direct payment from Blue Cross reduces administrative
expense and improves cash flow
• Blue Cross members have financial incentives to use
participating providers
• Participating providers’ names are included in directories that
we publish for our members
• Blue Cross contracts do not contain exclusivity clauses that
prohibit you from participating with other health plans
• Participating providers receive a Statement of Provider Claims
Paid explaining how claims are processed
• Opportunity to attend provider seminars offered free of charge
by Blue Cross
• Dedicated service staff available to assist participating
providers
• Electronic options such as provider web self-service to obtain
information
Responsibilities of being a participating provider include:
• Participating providers are required to electronically submit all
claims. Paper claims submitted by providers will be rejected
and will need to be submitted electronically. Blue Cross will
not consider such paper claims to have been received until
resubmitted electronically.
• Participating in the Blue Cross credentialing process.
• Participating in Blue Cross managed care programs.
2-2 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (01/05/10)

Responsibilities of
Participating Providers
(continued)
Provider Agreements
• Submitting preadmission notifications (PANs) or prior
authorizations or pre-certifications when required. PANs must
be submitted through provider web self-service.
• Exceptions to this are:
• non-rehab acute inpatient admissions to Bethesda
Hospital
• admissions for BlueLink TPA members
• if your clinic/facility does not have web access
• For these exceptions only, PANs may be faxed to
(651) 662-6860.
• Referring patients, whenever possible, to other participating
providers including, but not limited to, anesthesiologists,
radiologists, pathologists, surgical assistants and, where
applicable, to Select network providers.
• Accepting payment provisions outlined in the agreement. If
Blue Cross determines that services are experimental,
investigative, or not medically necessary, you may not bill the
patient unless you give the patient written notification of noncoverage
immediately before the services are performed and
the patient agrees in writing to be responsible for the services.
• Notifying Blue Cross of new programs prior to implementation
(i.e., technology, new procedures being performed).
• Maintaining confidentiality of our contractual and financial
arrangements.
• Each provider’s services must be within the scope of the
provider’s registration, license, and training and consistent
with community standards for quality and utilization.
• Not bill Blue Cross for any professional services provided by
physicians and health care professionals to themselves, their
immediate family members or those living in the same
household. Immediate family members include the physician’s
or health care professional’s spouse, children, parents or
siblings.
• Not bill members for missed scheduled appointments except
for a patient who misses a scheduled behavioral health
appointment, provided you have notified the member in
writing in advance that this is your policy. Please note that
PMAP, MinnesotaCare, and Medicare members may not be
billed for missed appointments.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (01/05/10) 2-3

Provider Agreements
Responsibilities of
Participating Providers
(continued)
Requirements of
Minnesota Law
• Promptly furnishing at the provider’s own expense any
additional information that Blue Cross or the plan sponsor shall
reasonably request as necessary to respond to claims,
utilization review, coordination of benefits, quality
improvement and care management reviews, pre-certification
reviews, preadmission notification, prior authorization, medical
necessity reviews, credentialing, and medical abstract reports.
The provider shall be responsible for obtaining any
authorization required to release such information to Blue
Cross or the plan sponsor.
• Provider will collect appropriate copayment amounts and not
waive these amounts.
• Billing the patient for noncovered services listed as exclusions
in the patient’s coverage certificate.
• Participating providers may not collect any difference between
the amount billed and Blue Cross’ allowance for health
services.
• Charging members of the general public the same amounts as
Blue Cross members (individual hardship cases are an
exception).
• Billing only for services personally performed by your medical
staff or other professionals employed by your facility that meet
the eligibility criteria defined by Blue Cross.
Minnesota law requires participating providers to look to Blue
Cross for payment of services covered by the member’s contract.
Following are requirements:
• Providers may not bill patients for services covered by their
Blue Cross health plan only in accordance with Minnesota law
for the applicable coinsurance, copayment or deductible and
providers may not withhold treatment in the event that a patient
is unable to make payment in advance and prior to Blue Cross
completing processing of the claim or adjustment.
• Providers may not refer a patient’s account to collection for
nonpayment of services covered by the Blue Cross health plan.
Copayments, coinsurance and deductibles can be coordinated
through the clinic’s normal billing, and if applicable, their
collections process.
• Interest on services covered by Blue Cross may not be applied
to a patient’s account.
2-4 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (01/05/10)

Requirements of
Minnesota Law
(continued)
Blue Cross'
Responsibilities
Written Notification
and Provider Liability
Provider Agreements
• Effective August 1, 2010, Minnesota Statute [62Q.751] states:
• Providers may collect deductibles and coinsurance from
patients at or prior to the time of service.
• Providers may not withhold a service to a health plan
company enrollee based on a patient's failure to pay a
deductible or coinsurance at or prior to the time of service.
• Overpayments by patients to providers must be returned to
the patient by the provider by check or electronic payment
within 30 days of the date in which the claim adjudication
is received by the provider.
Blue Cross’ responsibilities include the following:
• Make payment directly to the provider for covered services,
respond to inquiries and resolve claims in a timely manner
• Maintaining confidentiality of the provider’s charge data in
accordance with the contract terms
• Establishing a peer-review process to make decisions about
medical necessity
• Keeping members informed of participating providers through
publication of directories
• Keeping providers informed of changes which are
contractually binding through Provider Bulletins or other
communications (i.e. Provider Manual)
If it is necessary to recommend that a patient see a
nonparticipating provider, the participating physician must give the
patient advance, written notification that the recommendation is to
a nonparticipating physician. Once notice is given, the patient is
responsible for any increased liability if he or she decides to
schedule the service. If a patient is not properly informed, the
provider making the recommendation to a nonparticipating
provider will be liable for increased costs that a patient incurs.
Please refer to Waivers in Chapter 4.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (01/05/10) 2-5

Provider Agreements
Provider Numbers
Overview Blue Cross works with many different types of providers through
contractual agreements. Agreements are in place with facilities and
physician clinics to establish networks of participating providers
for our members.
National Provider
Number (NPI)
The Health Insurance Portability and Accountability Act-
Administrative Simplification (HIPAA-AS) is the result of
legislation passed by the U.S. Congress. The legislation mandates
standards for business to business electronic data interchange and
code sets, establishes uniform heath care identifiers and seeks
protection for the privacy and security of patient data.
The purpose of implementing the NPI is to improve the efficiency
and effectiveness of the health care system by reducing the number
of identifiers associated with any specific provider or provider
facility. Implementation will simplify provider identification and
billing processes across multiple third party payers (including
government programs) and prevent fraud and abuse.
The NPI is a unique all numeric 10 digit number that is assigned
by the Centers for Medicare & Medicaid Services (CMS). NPI
eligible providers are to submit transactions with the NPI at the
facility level as well as the practitioner level. Providers who are
considered Atypical (not eligible for an NPI) are to submit
transactions using their DHS assigned Unique Minnesota Provider
Identifier (UMPI) or the Blue Cross proprietary identification
number.
To register online or to find the NPI paper application form, access
the CMS website at http://nppes.cms.hhs.gov.
It is your responsibility to report your NPI to payers. To access the
NPI submission instructions, go to bluecrossmn.com for health
care providers, HIPAA/NPI Compliance.
2-6 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (01/05/10)

Credentialing
Provider Agreements
Overview Blue Cross and Blue Shield of Minnesota uses a credentialing
process to provide members with a selection of physicians and
other healthcare professionals who have demonstrated
backgrounds consistent with the delivery of high quality, costeffective
health care. We have established credentialing criteria for
network participation that is used to evaluate a provider’s
credentials. The credentialing criteria serve as the foundation for
determining a provider’s eligibility and continued eligibility in all
Blue Cross networks. Providers are expected to remain in
compliance with credentialing criteria at all times.
Credentialing
Requirements and
Processes
Questions about
Credentialing
To learn more about credentialing requirements and processes,
please reference the CREDENTIALING POLICY MANUAL
found at providers.bluecrossmn.com.
Call provider services at (651) 662-5200 or 1-800-262-0820.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (01/05/10) 2-7

Provider Agreements
Accounting for Disclosure Request
Guidelines for the
Accounting Disclosure
Request
Blue Cross and Blue Shield of Minnesota members have the right
to an accounting of certain disclosures that are made of their
protected health information (PHI) within six years prior to their
request. Blue Cross will fulfill these requests with a member
disclosure summary. Providers are requested to follow the
guidelines listed below and forward required disclosures to:
Blue Cross and Blue Shield of Minnesota and Blue Plus
Attention: Compliance and Regulatory Affairs
P.O. Box 64560
St. Paul, MN 55164-0560
When to Use the Form If a disclosure is subject to an accounting, providers must use the
enclosed form to record the disclosure information. This form can
be found on our website at bluecrossmn.com. Disclosures which
require an accounting include disclosures which are made:
1. pursuant to applicable law;
2. for cadaveric organ donation purposes;
3. to avert a serious threat to health or safety;
4. for certain marketing or fundraising exceptions; and
5. to the Secretary of Health and Human Services.
The attached form provides a more detailed list of those
disclosures that must be accounted for. Not all disclosures of an
individual’s PHI are subject to an accounting.
Providers are not required to account for disclosures they make:
• before the privacy rules compliance date (April 14, 2003)
• to the individual
• to or for notification of persons involved in an individual’s care
• for treatment, payment, or health care operations
• for national security or intelligence purposes
• to correctional institutions or law enforcement officials
regarding inmates
• for research if it involves at least 50 records and we provide
individuals with a list of all the research protocols and the
researcher’s name and contact information
• using de-identified health information
2-8 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (01/05/10)

Disclosures Related to
Your Status as a
Business Associate
Provider Agreements
Our agreement with you does not require that you account to us for
any and all disclosures that do not fall within the exceptions listed
above. We want to clarify how the disclosure requirements apply
to you as our business associates. As you are aware, we have
determined that you are our business associate because our
provider agreement with you requires you perform certain
activities on our behalf. We have identified these business
associate activities as:
• Compliance with and implementation of quality
improvement/managed care requirements such as providing
specific patient records for a quality study; and
• Receiving and resolving member complaints.
You would only need to account for disclosures of records that you
hold in your capacity as a business associate. For example, if you
report a complaint to Blue Cross as required by your Blue Cross
Provider Agreement, you are gathering that information and
forwarding it to us as our business associate. You do not have to
report the disclosure to us because it is part of health care
operations. If, however, a regulator were to audit our compliance
with handling member complaints and you had to release
correspondence or records to the regulator, which is a disclosure
you would have to account for. You created the record as our
business associate and disclosed to a regulator, which is the type of
disclosure that must be accounted for.
Another example would be records that you provided to us for
Child and Teen Checkups. If the Department of Health were to
decide to monitor managed care plans for child and teen checkups,
they may ask you for all the information you provided to Blue
Cross as part of the on-site audits. The disclosure is permitted to
the Department of Health without authorization as a public health
activity, but it must be accounted for.
You do not have to account for disclosure of records that you have
in your capacity as a provider. For example, as discussed above,
you might have medical records from providing a teen with a
checkup. Subsequently, the teen is involved in a crime and the
medical records are necessary for identification purposes. You
may disclose the medical record to law enforcement authorities
and must account to the teen for that disclosure. You do not,
however, have to account to Blue Cross for that disclosure.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (01/05/10) 2-9

Provider Agreements
Carrier Replacement Law
Carrier Replacement The Law
How Carrier
Replacement Works
The Minnesota Carrier Replacement Law applies when a group
terminates their fully insured coverage with one carrier and
replaces it with another fully insured group contract. This law
dictates how Blue Cross determines liability for charges incurred
by a member whose inpatient treatment occurred during this
change in coverage.
• The carrier whose coverage is in effect when a patient is
admitted to a facility is liable for all institutional charges
incurred by a member whose inpatient treatment spans the
change in coverage.
• The carrier in effect at the time of admission is liable for all
professional charges incurred up to the termination date of the
coverage.
• The new carrier is liable for all professional charges incurred
beginning on the effective date of the new coverage.
• The definition of “discharge” is the date the patient is formally
released from the inpatient facility with discharge papers
completed.
Continuous Stay Continuous stay occurs when the patient is sent to another facility
for services unavailable at the current facility and no discharge or
admission papers are processed upon transfer.
• In the case of a patient who is discharged and transferred to
another facility, both the transportation and charges incurred at
the new facility will become the liability of the new carrier.
When… Then…
a new member was hospitalized
prior to the effective date of
Blue Cross coverage
a new member remains
hospitalized on and after the
first date of coverage
the new member’s other carrier
stops paying for the
hospitalization or there is no
other carrier
Blue Cross and Blue Shield of
Minnesota pays the hospital
claim on a pro rata basis
beginning on the date coverage
becomes effective.
2-10 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (01/05/10)

Provider Agreements
Public Programs DHS requires the health plan active at the time of patient
admission to be responsible for all services associated with an
inpatient stay until the discharge date. This includes both facility
and professional charges.
Federal Employee
Program
• All services occurring after the termination date of the contract
for Individual contracts are denied as “No Coverage”.
• Medicare supplement contracts will cover the Medicare
inpatient deductible. However, Medicare Coinsurance Days are
denied after the coverage termination.
When Federal Employee Health Benefits coverage ends, the
employee and eligible dependents may receive an additional 31
days of coverage, for additional premium, when:
• enrollment ends, unless the employee cancels their enrollment
or
• the employee family members are no longer eligible
The employee may be eligible for spouse equity coverage or
Temporary Continuation of Coverage (TCC), or a conversion
policy.
InstaCare SM This Contract terminates at the end of the contract term selected on
the Contract Schedule and Application, except in instances where
the member or their covered dependents are confined to a hospital
on that date. For that person, we will extend the contract term only
for the condition causing the hospital confinement. The extension
will end when the person is no longer confined to the hospital or
when the lifetime maximum has been paid, whichever occurs first.
Self-funded Groups
and Minnesota
Advantage Health Plan
Carrier Replacement law does not apply to self-insured business.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (01/05/10) 2-11

Table of Contents
Chapter 3
Quality Improvement
Introduction to Quality Improvement ..................................................................................... 3-2
General Overview ..................................................................................................................3-2
Basic Elements of a QI Program............................................................................................3-2
Leadership..............................................................................................................................3-3
Quality Improvement Projects ..............................................................................................3-3
Cooperation with Blue Cross QI Program............................................................................. 3-4
Telephone Care: During Office Hours...................................................................................3-4
Telephone Care: In-coming Calls .......................................................................................... 3-4
Telephone Care: After Hours.................................................................................................3-5
Complaint Review System..................................................................................................... 3-6
Quality of Care Complaints ...................................................................................................3-7
Access & Availability............................................................................................................3-7
Written Policies......................................................................................................................3-8
Continuity and Coordination of Care................................................................................... 3-11
Patient Safety .......................................................................................................................3-12
Medical Record Keeping Practices...................................................................................... 3-13
Medical Record Documentation .......................................................................................... 3-14
Clinical Practice Guidelines.................................................................................................3-16
Quality Improvement for Behavioral Health Providers ...................................................... 3-19
General Overview ................................................................................................................3-19
Cooperation with Blue Cross QI Program........................................................................... 3-19
Complaint Review System................................................................................................... 3-20
Additional requirements for Select Network Providers....................................................... 3-20
Access and Availability .......................................................................................................3-20
Physical Facility...................................................................................................................3-21
Written Provider Policies..................................................................................................... 3-22
Treatment Record Documentation.......................................................................................3-23
Blue Cross Blue Shield of Minnesota Provider Policy and Procedure Manual (08/11/11) 3-1

Quality Improvement
Introduction to Quality Improvement
General Overview This chapter contains detailed information about the Blue Cross
Quality Improvement (QI) program. The information provided in
this chapter is intended for all Aware providers, however; some
requirements may not apply in every facility. Additionally, some
requirements for behavioral health providers are different than
those described below. Requirements that are different or more
stringent for behavioral health providers are detailed in the Quality
Improvement for Behavioral Health Providers section. The
material also explains what is expected from participating
providers regarding their quality programs and defines provider
requirements including medical record keeping practices.
Basic Elements of a QI
Program
Rationale:
Blue Cross subscribes to the philosophy of Quality Improvement
(QI) and the multifaceted benefits it offers. All providers
associated with our Blue Cross networks must include quality
improvement activities in their facilities. Striving to meet or
exceed customer expectations should be a driver for a successful
program. A well-established program enables you to discover root
causes, use data to increase production, and maximize your
available resources. A successful program has three basic
elements: it must be customer-focused, data-driven, and processoriented.
Blue Cross supports the six aims for improvement identified in the
Institute of Medicine’s Crossing the Quality Chasm. These six
aims are that care should be safe, effective, patient-centered,
timely, efficient, and equitable. All Blue Cross providers are
expected to incorporate these aims into their Quality Improvement
programs. Some models are available to guide and direct QI
project efforts.
Requirements:
• Provide annual QI program report upon request to Blue Cross.
3-2 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/11/11)

Quality Improvement
Leadership Rationale:
Quality Improvement
Projects
Leadership within an organization must support and embrace the
philosophy of Quality Improvement for it to succeed. Advising,
supporting, and actively participating in the development and
implementation of process improvement is a vital function of
leadership.
Improving processes within an organization promotes better care
and services to customers, creating a marketplace advantage.
Requirement:
• Designated QI Medical Director, who is a practicing physician
and is either a MD or DO.
Rationale:
Addressing problems or opportunities within your facility using
the QI process offers distinct advantages. Quality Improvement
projects employ systematic analysis of current practices to reveal
refined approaches to everyday operations. Using a defined model
means that changes can be tested and adopted effectively.
Requirements and changes regarding QI reporting are distributed
annually in the first quarter to all main site primary care providers.
Suggested project categories may include clinical guideline
implementation or improvement, administrative or processoriented
improvements, or improvements based on customer
feedback. Often providers choose to do one project that is clinical
and one that is service-related.
We encourage you to conduct a survey or focus group of
customers as you develop system changes. Blue Cross does not
routinely collect project information from providers however,
requirements remain the same. The requirements listed below
should be followed if your facility chooses to implement
improvement activities.
Requirements:
• Provide QI program description, contact information, or
project reports upon request.
• Clinical projects must be based on approved and established
guidelines [i.e., Institute for Clinical Systems Improvement
(ICSI)].
• Projects have completed a full PDCA Cycle or Seven-Step
process. Refer to the PDCA or Seven-Step Process
information.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/11/11) 3-3

Quality Improvement
Cooperation with Blue
Cross QI Program
Telephone Care:
During Office Hours
Telephone Care:
In-coming Calls
Rationale:
Collaborative efforts need to mutually service our
members/patients with excellent care and services.
Requirements:
• Consultation and cooperation to resolve individual patient
complaints.
• Provide medical records for QI purposes upon request.
• Collaborate on corrective action plan when Blue Cross quality
thresholds are not met. The Blue Cross Quality Council
determines thresholds.
Rationale:
Patients need telephone access to medical care with a response
time based on the urgency of their symptoms.
Requirements:
During office hours, members calling a provider will be assessed
according to patient care needs by a physician or designee:
• Immediately for emergencies, 100% of the time
• Within 30 minutes for urgent issues, 85% of the time
• Within four hours for all other call types, 85% of the time
Rationale:
A timely response to incoming phone calls promotes patient
satisfaction.
Requirements:
• Calls answered in six rings or fewer
• On hold two minutes or less
3-4 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/11/11)

Quality Improvement
Telephone Care:
After Hours
Rationale:
Patients must have access to instructions for obtaining care 24
hours a day, 7 days a week, and 365 days a year. When patients
call your facility outside of routine business hours, it is important
that they are able to receive directions on how to obtain care and
get answers to their questions. To achieve this, providers must
have a telephone number that is answered 24 hours a day by either
a live person, or an answering system that will provide patients
information as outlined below.
• The name of the clinic that the patient is calling is clearly
stated.
• Specific instructions on what the patient should do if they feel
their situation is a medical emergency. This is often stated, “If
you feel this is a medical emergency please hang up and dial
911."
• Information regarding who the patient should call if it is not a
medical emergency, but feel they need medical advice. Be
certain to include the name, area code and telephone number of
the individual or clinic to whom they are being directed.
• If the patient is directed to leave a message, an acceptable call
back time frame must be provided to the patient awaiting the
return call.
• All instructions should be articulated slowly and clearly in
terms understandable to non-health care professionals.
Additional tips:
• If you are using an electronic answering system, minimize
excess background noise when recording your message and
make sure the recording volume is set to an appropriate level.
• If you are instructing the patient to call another location, that
location must also have a detailed message or someone
answering the phone that will provide the patient instruction on
obtaining medical care or advice.
• It is recommended that you audit your message according to
these guidelines outside of normal business hours to make
certain you are in compliance with the requirements.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/11/11) 3-5

Quality Improvement
Telephone Care:
After Hours
(continued)
Complaint Review
System
Requirements:
To provide all primary care patients access to a 24 hour telephonic
resource that clearly articulates and identifies back-up coverage by
another participating primary care physician; and referrals to
urgent care centers, where available, and/or to hospital emergency
care. Additionally, incorporating standards for call-back times
based on what is medically appropriate to each situation when the
patient must leave a message.
Rationale:
Patient complaints, concerns and grievances reflect their
perceptions and expectations. Feedback, whether solicited or
unsolicited, presents an opportunity to identify issues and
implement systematic processes to improve the quality of care or
service. Aware providers and Blue Cross share a joint commitment
to patient satisfaction and to the improvement of care and services
delivered to Blue Cross members.
Requirements:
All providers will have a policy and procedure in place detailing
the following:
• Process to receive written and verbal complaints for Blue
Cross members
• Designate an individual to be the primary contact for complaint
management, including the tracking of such complaints
• Document the substance of the complaint, the investigation,
and any actions taken
• Notify members of the right to complain and appeal to their
health plan
• Track complaints by categories and report at least annually to
an in-house committee
3-6 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/11/11)

Quality Improvement
Quality of Care
Complaints
Access & Availability Rationale:
A quality of care complaint is an additional right of Blue Cross
members. Members may complain if they feel the quality of their
care has been compromised.
Some examples when members may file a complaint are:
• They are not receiving an appointment in a reasonable amount
of time.
• The PCC is not referring them to a specialist when it is
necessary.
• The provider/provider office was rude or discourteous.
• The provider is unable to diagnose or treat their condition.
• There is a delay in communicating test results.
• Confidentiality or privacy concern.
• Incorrect test ordered or performed.
• Infection control.
• Equipment malfunction, cleanliness.
We immediately supply the provider with a copy of the member’s
complaint and involve the provider in the solution. We are
required by the Department of Health to acknowledge these
complaints within 30 days of receipt therefore we require your
expedited attention to any request we may have.
Members’ concept of the quality of care they receive often begins
when they make an appointment. Blue Cross also wants to insure
that members are able to schedule appointments within a timely
manner, relative to the services they seek.
Requirements:
Satisfaction – Primary Care Providers Only
• Routine Care: 85% of members will usually or always be
satisfied with when they get a routine care appointment
(routine care is that which the member does not need to see a
practitioner right away.)
• Urgent Care: 85% of members will usually or always be
satisfied with when they get an urgent care appointment
(urgent care is that which is needed right away for an illness,
injury or condition).
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/11/11) 3-7

Quality Improvement
Access &
Availability
(continued)
Wait Times
Written Policies Rationale:
• Preventive Care – within 30 days 85% of the time for well
child exam, annual physical exam, etc.
• Routine Primary Care – within 7 days 85% of the time for
non-urgent symptomatic conditions.
• Urgent Care – Same day 85% of the time for medically
necessary care which does not meet the definition of
emergency care.
• Emergency Care – Immediate 100% of the time for
immediately life threatening illnesses, injuries and conditions.
To protect the safety and privacy of all patients, and for the
protection of the provider, Blue Cross requires all providers to
develop and implement written policies and procedures applicable
to the services they provide. Providers are encouraged to have
policies that are facility specific, signed, dated and reviewed
annually.
Requirement:
Each provider will have policies and procedures in place for the
following topics that apply to the services provided in the facility.
Policy Required Recommended Risk Management Elements
Advance
Directives
Child and Teen
Check-ups
• Information made available
• Discussion is documented in medical record
• Copies retained
• Hospitals notified upon admission
• Eligibility defined (birth through age 20,
MA, PMAP, MNCare children)
• Forms for documentation addressed
• Age-appropriate services defined
• Documentation in medical record
• Correct coding
3-8 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/11/11)

Quality Improvement
Written Policies
(continued)
Policy Required Recommended Risk Management Elements
Communicable
Disease
Reporting
Complaint
Management
• Requirement to report communicable
diseases by State Health Department
• Reporting timeframe (within one day)
• Responsibility of reporting defined
• Forms, completion and submittal addressed
• See Complaint Review System Section
Confidentiality • Training, including how soon initial training
occurs, when or how often refresher training
occurs, verified by signatures of trainer and
individual being trained, and on file for six
years
• Accountability, including how control is
maintained (i.e., who has keys, who is
allowed into the facility and when)
• Protected health information (PHI) disposal
• Security of both paper and electronic PHI,
follow HIPAA guidelines
• Reviewed annually
Confidentiality
and Security of
Medical
Records
Foreign
Language
Translation and
Hearing
Impaired
Services
• Refer to the Medical Records section
• Assistance provided for both situations
• Interpreter available for phone calls and
face-to-face interactions
• Patients/family are notified that interpreter
is provided
• Resources are identified
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/11/11) 3-9

Quality Improvement
Written Policies
(continued)
Policy Required Recommended Risk Management Elements
Hazardous
Materials and
Waste
Management
Infection
Control
Medical
Emergency
• Written plan in place and maintained
• Hazardous material and waste defined
• Mechanism in place for responding to a spill
• MSDS (material safety data sheets)
available
• Hazardous materials and waste are
identified and inventoried
• Mechanism defined for responding to a
spill/breach of containment
• Chemical and regulated medical waste
addressed
• Hazardous gas and vapors addressed
• Orientation and education of staff outlined
• Basic overview of infection control and how
it relates to controlling disease
• Hand washing outlined, when and how
• Universal precautions addressed, including
glove use
• Personal protection equipment addressed
• Screening employees for TB
• Vaccinating employees for Hepatitis B
• Steps taken when employee is exposed to
breach of infection control or exposure, how
to report to OSHA
• Mechanism in place for responding
• Medical emergency code is identified
• Identify who directs activities
• Identify who determines if 911 is called
3-10 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/11/11)

Quality Improvement
Written Policies
(continued)
Continuity and
Coordination of Care
Policy Required Recommended Risk Management Elements
Medication
Management
Non-Medical
Emergency
Policy
Treating
Unaccompanied
Minors Policy
Rationale:
• Mechanism in place for procuring, storing,
controlling and distributing medications
• Narcotics addressed, even if to say they are
not kept at the facility
• Recalls addressed
• Emergency and sample drugs addressed
• Sign-out log covered
• Prescription pad accessibility addressed
• Mechanism in place for responding
• Include power outages, weather
emergencies, bomb threats, and both fire
and fire drills
• Minor defined, exceptions covered
• Scheduling appointments addressed
• Mechanism in place to respond when an
unaccompanied minor calls/arrives asking to
be seen
• Sample of authorization to consent to
treatment of a minor is provided
Patient continuity and coordination of care (COC) across settings
such as inpatient and ambulatory care and transition from specialty
to primary care, is critical in ensuring the best care for our
members and your patients. All providers share a joint
responsibility to ensure continuity and coordination of care.
Guidelines:
Health Records:
• Establish a consistent location(s) for external communications
from facilities and/or consultants including but not limited to
discharge summaries or notes, consult letters, progress notes,
and test or lab results.
• Communication is maintained in a chronological order.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/11/11) 3-11

Quality Improvement
Continuity and
Coordination of Care
(continued)
Referrals:
• Communicate with specialists/consultants the rationale for the
referral (is the patient being referred for a consultation or
ongoing care) and set expectations for future communications.
• Information, radiology, lab/test results, etc. are made available
to the specialist/consultant in time for the patient’s visit.
Specialty Care and Consultants:
• Provider written communication to the patients’ primary care
provider including, but not limited to progress notes,
consultation letters, and test or lab results.
Inpatient:
• The attending physician copies all discharge summaries and
discharge notes to the primary care provider.
Emergency and Urgent Care:
• Correspondence regarding all emergency room and urgent care
visits are copied to the primary care provider.
Patient Safety Blue Cross is committed to establishing high standards of care for
our members. In order to assure these high standards, we expect
all participating practitioners and providers to be familiar with and
actively involved in patient safety practices. We support the work
of the Leapfrog Group, a national coalition of major employer
groups, which has established patient safety standards. Blue Cross
also supports national health improvement initiatives, such as the
recent “5 Million Lives Campaign” sponsored by the Institute for
Health Improvement.
Blue Cross also works to ensure patient safety by monitoring and
addressing quality-of-care issues identified through pharmacy
utilization data, continuity and coordination of care standards,
disease management program follow-up, and member complaints.
3-12 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/11/11)

Quality Improvement
Patient Safety
(continued)
Medical Record
Keeping Practices
Resources
Resources are available to you for information and to assist in the
continuation of safe practices.
The following websites have patient safety programs and materials
that you may find useful:
Website Website Address
Agency for Healthcare Research and
Quality (Dept of HHS)
www.ahrq.gov
Institute for Healthcare Improvement www.ihi.org
The Joint Commission International
Center for Patient Safety
www.jcipatientsafety.org
Leapfrog Group for Patient Safety www.leapfroggroup.org
Minnesota Alliance for Patient Safety www.maps.org
National Quality Forum www.qualityforum.org
Rationale:
Blue Cross requires its providers to have a policy and procedure
for confidentiality of health information and medical records that
meet state and federal requirements.
Blue Cross expects strict adherence to state and federal laws with
regards to maintaining members’ medical information and records
in a confidential manner. Blue Cross requires medical records to
be maintained in a manner that is current, detailed and organized.
Providers must have a tracking process in place for ease of
retrieval.
Requirements:
• A written policy and procedure of medical record keeping
practices, which includes the confidentiality and security of
medical records, and release of information, is available.
• Medical records are kept in a secure or electronically secure
location.
• Review of the confidentiality policy and procedure is
performed at least annually with staff.
• A tracking system for medical records is in place.
• The medical record forms are available for release.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/11/11) 3-13

Quality Improvement
Medical Record
Documentation
Rationale:
The patient medical record is a vehicle for documenting services
provided and evaluating continuity and coordination of care. It also
serves as legal protection for the patient and practitioner. Blue
Cross, per contractual agreement with both the subscriber and
provider, has access to the member’s medical record for
examination and evaluation. Blue Cross’ corporate confidentiality
policy requires that the personal and health information of its
members be maintained as confidential information. All employees
are required to attest to their knowledge of this policy and their
intent to comply with it.
Medical record review is an essential component of a
comprehensive Quality Improvement program. The Blue Cross
Quality Council, which includes practicing physicians, establishes
minimum patient medical record documentation standards.
Requirements:
All providers will have a policy and procedure in place to address
the following:
Format
• The content and format of the medical record is organized and
includes patient’s address and home and work phone numbers.
• Each page in the medical record contains the patient’s name or
identification number.
• All entries in the medical records contain the author’s
identification. Author identification may be a handwritten
signature, a unique electronic identifier, or a stamped signature
verified with initials.
• Medical records are legible to someone unfamiliar with the
author’s handwriting.
• All encounters/entries are dated.
• Immunization status information for all ages is recorded on a
single page location.
• A summary of preventive services screening is documented in
a consistent place.
3-14 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/11/11)

Quality Improvement
Medical Record
Documentation
(continued)
Content
• Medication allergies and adverse reactions are prominently
noted in the record. If the patient has no known allergies or
history of adverse reactions, this is appropriately noted in the
record.
• Significant illnesses and medical conditions are indicated on a
problem list.
• Past medical history (for patients seen three or more times) is
easily identified and includes, as appropriate, significant family
history, serious accidents, operations and illnesses. For
children and adolescents (18 years and younger), past medical
history relates to prenatal care, birth, operations and childhood
illnesses.
• For patients 10 years and older, there is an appropriate notation
concerning the use of tobacco, alcohol and substances.
• The history and physical exam identifies appropriate subjective
and objective information pertinent to the patient’s presenting
complaints and includes medications.
Assessment and Plan
• Laboratory and other studies are ordered, as appropriate
• Assessment of each encounter reflects patient’s chief
complaint
• Treatment plans are consistent with diagnoses
Follow-up
• Encounter forms or notes have a notation, when indicated,
regarding follow-up care calls or visits. The specific time of
return is noted in weeks, months or as needed.
• Unresolved problems from previous office visits are addressed
in subsequent visits.
• If a consultation is requested, there is a note concerning this
visit in the record.
• Consultation, lab and imaging reports filed in the chart are
reviewed by the primary care physician.
• Clinically significant abnormal consultation results, lab or
imaging study results have an explicit notation in the follow-up
plans.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/11/11) 3-15

Quality Improvement
Clinical Practice
Guidelines
Institute for Clinical Systems Improvement (ICSI)
Website Website Address
ACS: Diagnosis and Treatment
of Chest Pain and Acute
Coronary Syndrome
Diagnosis and Management of
Asthma
ADHD, Attention Deficit
Hyperactivity Disorder in
Primary Care for Children and
Adolescents
At Blue Cross and Blue Shield of Minnesota and Blue Plus, we
believe that the use of clinical practice guidelines is a key
component of Quality Improvement. Each year our Quality
Council approves the adoption of select guidelines that are used to
support various programs and initiatives. The guidelines do not
substitute for sound clinical judgment; however, they are intended
to assist clinicians in understanding key processes for
improvement efforts.
Please note that some treatment and management options
recommended in clinical practice guidelines may not be covered
benefits under a Blue Cross and Blue Shield of Minnesota and
Blue Plus member’s health plan.
http://www.icsi.org/guidelines_and_more/gl_os_prot/cardi
ovascular/acs_acute_coronary_syndrome/acs__acute_coro
nary_syndrome_and_chest_pain__diagnosis_and_treatme
nt_of__full_version_.html
http://www.icsi.org/guidelines_and_more/gl_os_prot/respi
ratory/asthma__outpatient/asthma__diagnosis_and_outpa
tient_management_of_12572.html
http://www.icsi.org/guidelines_and_more/gl_os_prot/beha
vioral_health/adhd/adhd_in_primary_care_for_children_
__adolescents__diagnosis_and_management_of_.html
Colorectal Cancer Screening http://www.icsi.org/guidelines_and_more/gl_os_prot/preve
ntive_health_maintenance/colorectal_cancer_screening/col
orectal_cancer_screening_6.html
Diagnosis and Management of
Chronic Obstructive
Pulmonary Disease (COPD) by
ICSI
Major Depression in Adults in
Primary Care
Diagnosis and Management of
Diabetes in Adults, type 2
http://www.icsi.org/guidelines_and_more/gl_os_prot/respi
ratory/chronic_obstructive_pulmonary_disease/chronic_o
bstructive_pulmonary_disease__guideline_.html
http://www.icsi.org/guidelines_and_more/gl_os_prot/beha
vioral_health/depression_5/depression__major__in_adults
_in_primary_care_4.html
http://www.icsi.org/guidelines_and_more/gl_os_prot/other
_health_care_conditions/diabetes_mellitus__type_2/diabet
es_mellitus__type_2__management_of___6.html
3-16 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/11/11)

Quality Improvement
Institute for Clinical Systems Improvement (ICSI)
Website Website Address
Healthy Lifestyle http://www.icsi.org/chronic_disease_risk_factors__primar
y_prevention_of__guideline__23506/chronic_disease_risk_
factors__primary_prevention_of__guideline__23508.html
Heart Failure in Adults http://www.icsi.org/guidelines_and_more/gl_os_prot/cardi
ovascular/hypertension_4/hypertension_diagnosis_and_tre
atment__11.html
Immunizations http://www.icsi.org/guidelines_and_more/gl_os_prot/preve
ntive_health_maintenance/immunizations___guideline_/i
mmunizations__guideline__38399.html
Lipid Management in Adults http://www.icsi.org/guidelines_and_more/gl_os_prot/cardi
ovascular/lipid_management_3/lipid_management_in_adu
lts__4.html
Low Back Pain, Adult by ICSI http://www.icsi.org/guidelines_and_more/gl_os_prot/musc
ulo-skeletal/low_back_pain/low_back_pain__adult_5.html
Prevention and Management of
Obesity
http://www.icsi.org/for_patients/for_patients_families/obes
ity__mature_adolescents_and_adults___prevention___ma
nagement_of__for_patients___families_.html
Preventive Services for Adults http://www.icsi.org/guidelines_and_more/gl_os_prot/preve
ntive_health_maintenance/preventive_services_for_adults/
preventive_services_for_adults__11.html
Preventive Services for
Children and Adolescents
http://www.icsi.org/guidelines_and_more/gl_os_prot/preve
ntive_health_maintenance/preventive_services_for_childr
en__guideline_/preventive_services_for_children_and_ado
lescents_762.html
Routine Prenatal Care http://www.icsi.org/guidelines_and_more/gl_os_prot/wom
ens_health/prenatal_care_4/prenatal_care__routine__3.ht
ml
Stable Coronary Artery
Disease (CAD)
http://www.icsi.org/guidelines_and_more/gl_os_prot/cardi
ovascular/coronary_artery_disease/coronary_artery_disea
se__stable__3.html
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/11/11) 3-17

Quality Improvement
Other
Website Website Address
KDOQI Clinical Practice
Guidelines for Chronic Kidney
Disease from NKF
NCCN Clinical Practice
Guidelines in Oncology
(copyrighted material; need
registration)
NIAAA Helping Patients Who
Drink Too Much
SAMHSA Substance Abuse
Treatment for Persons with Co-
Occurring Disorders
http://www.kidney.org/professionals/kdoqi/guidelines_ckd
/toc.htm
http://www.nccn.org/professionals/physician_gls/f_guideli
nes.asp
http://pubs.niaaa.nih.gov/publications/Practitioner/Clinici
ansGuide2005/clinicians_guide.htm
https://ncadistore.samhsa.gov/catalog/productDetails.aspx
?ProductID=16979
3-18 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/11/11)

Quality Improvement
Quality Improvement for Behavioral Health
Providers
General Overview This section contains detailed information about the Blue Cross
Quality Improvement (QI) program that is specific to behavioral
health providers. The information in this section is in addition to or
more specific than the requirements in the greater chapter. The
material explains what is expected from participating providers
regarding their quality programs and defines provider
requirements.
Cooperation with Blue
Cross QI Program
Rationale:
Collaborative efforts need to mutually serve our members/patients
with excellent care and services.
Requirements:
Actively participate in the following Blue Cross QI activities.
Standardized substance abuse screening in mental health
assessment.
• Routinely incorporate a substance abuse screening
questionnaire, e.g., CAGEAID, AUDIT, during mental health
assessment of new patients age 12 and under.
• Recommend or complete diagnostic assessment for a substance
use disorder based on positive screening results and
corroborating clinical information.
Exchange of information with primary care physicians
• Routinely ask new patients to authorize communication with
their physician and document authorization or refusal.
• When authorized, document communication with the
physician, e.g., report, letter, telephone or email.
• Authorized communication should include diagnosis, general
treatment plan, and if treated by a psychiatric practitioner,
initial medication management information.
Standardized treatment response monitoring for depression
• Routinely administer the Patient Health Questionnaire-9 for
adults with Major Depressive or Dysthymic Disorder to
monitor treatment response.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/11/11) 3-19

Quality Improvement
Complaint Review
System
Additional
requirements for
Select Network
Providers
Rationale:
The practice of managing patient complaints in behavioral health
clinics is consistent with practices in primary care clinics. Please
review the Complaint Review System section found under
Introduction to Quality Improvement for additional information on
maintaining a complaint review system.
Requirements:
Access and Availability Rationale:
All providers will have a policy and procedure in place detailing
the following:
• Process to receive written and verbal complaints for Blue
Cross members
• Designate an individual to be the primary contact for complaint
management, including the tracking of such complaints
• Document the substance of the complaint, the investigation,
and any actions taken
• Notify members of the right to complain and appeal to their
health plan
• Track complaints by categories and report at least annually to
an in-house committee
Members’ concept of the quality of care they receive often begins
when they make an appointment. Blue Cross wants to ensure that
members are able to schedule appointments in a timely manner;
commensurate with the level of care they need.
Requirements:
Routine initial appointments: 90% of requests within 10 business
days. Routine care is defined as a circumstance in which the
individual does not present either emergent or urgent conditions
and requests clinical services.
Follow-up appointment: 90% of requests within 10 business days
of the initial appointment.
3-20 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/11/11)

Quality Improvement
Physical Facility Rationale:
Urgent appointment: 100% of requests within 24 hours. Urgent
care is defined as a circumstance in which the individual presents
no emergency or immediate danger to self or others; however, the
individual, clinician, or concerned party believes that the
individual’s level of distress and/or functioning warrants
assessment as soon as possible. An urgent condition is a situation
that has the potential to become an emergency in the absence of
prompt treatment.
Non-life-threatening emergency appointment: 100% of requests
within 6 hours. A non-life-threatening emergency is defined as a
circumstance in which the individual is experiencing a severe
disturbance in mood, behavior, thought, or judgment. There may
be evidence of uncontrolled behavior and/or deterioration in ability
to function independently that could potentially require intense
observation, restraint, or isolation.
Emergency care: 100% of member requests immediately. An
emergency is defined as a circumstance in which there is imminent
risk of danger to the physical integrity of the individual; the
individual cannot be maintained safely in his or her typical daily
environment.
Blue Cross requires behavioral health clinics to provide a safe
environment, which protects patient privacy and ensures handicap
accessibility for disabled patients. Blue Cross will monitor and
review physical environment to evaluate conformity with
regulatory, plan, and accreditation standards.
Requirements:
• Provider is open reasonable working hours
• Provide 24 hour/7 day on-call coverage
• Accessibility for handicapped members as defined by the
Americans with Disabilities Act, 1990
• Controlled substances are secure in a locked cabinet or space
and dispensation is logged
• A system is in place to ensure that all medications are within
the expiration date
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/11/11) 3-21

Quality Improvement
Written Provider
Policies
Rationale:
To protect the safety and privacy of all patients, and for the
protection of the clinic, Blue Cross requires all behavioral health
clinics to develop and implement written policies and procedures.
Providers are encouraged to have policies that are specific to the
clinic and are signed, dated and reviewed annually.
Requirement:
Each clinic will have policies and procedures in place for the
following topics in addition to policies listed previously in this
chapter including Complaint Management, Confidentiality,
Confidentiality and Security of Medical Records, Foreign
Language Translation and Hearing Impaired Services, Medical
Emergency, Medication Management (if applicable), Non-Medical
Emergency Policy and Treating Unaccompanied Minors.
• Behavioral Health Accessibility Standards
Policy Required
Behavioral Health
Accessibility
Standards
Recommended Risk Management
Elements
• Access to behavioral health
appointments commensurate with
clinical need
• Access to follow-up appointments
commensurate with clinical need
• Crisis access to clinician 24 hours a
day/7 days a week
3-22 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/11/11)

Quality Improvement
Treatment Record
Documentation
Rationale:
The patient behavioral health treatment record is a vehicle for
documenting services and evaluating continuity and coordination
of care. It also serves as legal protection for the patient and
practitioner. Blue Cross, per contractual agreement with both the
subscriber and provider, has access to the member’s record for
examination and evaluation. Blue Cross’ corporate confidentiality
policy requires that the personal and health information of its
members be maintained as confidential information. All employees
are required to attest to their knowledge of this policy and their
intent to comply with it.
Treatment record review is an essential component of a
comprehensive Quality Improvement program. The Blue Cross
Quality Council establishes minimum record documentation
standards.
Annually, Blue Cross audits a random sample of patient records
from the Blue Cross population. The records are reviewed in
accordance with the required documentation elements. If potential
deficiencies are identified at a given site, a more intensive review
may occur.
Requirements for Treatment Record Format and Content
Record Organization
• The format of the treatment record must be logical and
organized.
• All forms used in the treatment process must be standardized
and consistent for all records.
• The treatment record must contain the patient’s current
address, employer or school, home and work phone numbers,
marital or legal status, appropriate consent forms, and
guardianship status information.
• Special status situations, such as imminent risk of harm,
suicidal or homicidal ideation, or elopement potential, must
be prominently documented and updated.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/11/11) 3-23

Quality Improvement
Treatment Record
Documentation
(continued)
• There must be a signed patient authorization for all external
persons with whom treatment information is exchanged. No
treatment information can be exchanged without patient
authorization or court order.
• Each page in the record must contain the patient’s name or
identifying number.
• All entries must be dated and contain the author’s name,
professional degree/designation, and relevant identification
number if applicable. If a non-degreed professional completes
the entry, the title of the author must accompany the signature,
e.g., Family Skills Worker. Author identification may be a
handwritten signature or unique electronic identifier. Initials
alone are not an acceptable form of identification. Initials may
be used in conjunction with a typed signature block that clearly
identifies the author.
• Errors in documentation must be corrected with a single line
drawn through the error with the author’s initials.
Initial Assessment
• Presenting problem(s), as well as relevant psychological or
social conditions affecting the patient's medical or psychiatric
status, must be documented.
• Presenting symptoms that are consistent with DSM-IV-TR
criteria must be clearly identified and documented, including
the onset, duration, and intensity of symptoms as well as
functional impairment.
• A psychiatric history must be documented. The psychiatric
history should include, if applicable, previous treatment dates,
identification of former treating practitioner(s), therapeutic
interventions and responses, relevant family psychiatric
history, lab test results, and consultation reports.
• A medical history must be documented which includes current
and/or past major or chronic medical conditions and a current
list of medications. Medication allergies and adverse reactions
must be prominently noted. If the patient has no known
allergies or history of adverse reactions, this must be noted.
• For children and adolescents through age 17, a comprehensive
developmental history must be documented that includes
prenatal and perinatal events, achievement of developmental
milestones, and psychological, social, intellectual, and
academic history.
3-24 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/11/11)

Quality Improvement
Treatment Record
Documentation
(continued)
• For individuals 10 years and older, a substance use history
must be documented. The history must include past and present
use of tobacco, alcohol, illicit drugs and any misuse of
prescription or over-the-counter drugs. Additionally, negative
consequences of use and history of assessment and/or
treatment should be documented.
• Standardized substance abuse screening questionnaire results
should be incorporated into the assessment of all new patients
12 years and older.
• A social history that includes family history, current family
status, history of physical, sexual or mental abuse or trauma,
current social network, and academic or vocational status must
be documented.
• A mental status examination which includes, at minimum,
information about appearance, speech, affect, mood, thought
content, judgment, insight, attention, concentration, memory,
and impulse control must be documented.
• A risk assessment that identifies level of risk for harm,
including suicidal, homicidal or elopement risk, must be
predominantly documented.
• Patient strengths and weaknesses that enable or inhibit the
individual’s ability to achieve treatment goals must be
documented.
• An initial treatment plan must be documented.
• All behavioral health practitioners must attempt consultation
and coordination of treatment with the patient’s primary care
or treating physician. Patient authorization must be obtained
prior to the release of any information. If the patient does not
wish to have treatment information exchanged, patient refusal
must be documented.
Diagnosis
• A DSM-IV-TR diagnosis must be documented. The diagnosis
must be consistent with presenting problems, symptoms,
clinical history, mental status exam, and other clinical data.
• All fives axes must be documented according to the DSM-IV-
TR multi-axial diagnostic system. The fifth digit of Axes I and
II diagnoses must be listed when applicable.
• ICD-9-CM codes must be used when submitting claims for
payment.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/11/11) 3-25

Quality Improvement
Treatment Record
Documentation
(continued)
Treatment Plan
• The treatment plan must be comprehensive, current, and
consistent with the diagnosis. The formal treatment plan must
be completed within the first three visits.
• The treatment plan must contain clear, objective, and
measurable goals as well as the estimated timeframes for goal
attainment or problem resolution. Interventions must be
appropriate for the diagnosis and/or presenting problem(s).
• The patient must participate in the development of the
treatment plan and should sign the initial plan and sign or
initial all updates or revisions.
Progress Notes
• All entries must contain the date, actual face-to-face contact
time, and current diagnosis.
• All entries must document the persons present during the visit
without using the names of persons other than the identified
patient.
• The interventions must be consistent with the diagnosis and
correspond with current treatment goals.
• Recommendations or referrals for preventive or other external
services, e.g., stress management, relapse prevention, or
community services, must be documented.
• The documentation of each entry must clearly state the chief
complaint and current status of symptoms as well as patient
strengths and limitations in reaching treatment goals.
• There must be a notation in each entry about need for followup
care, plans for a return visit, or termination of treatment.
The specific date or timeframe of a return visit must be noted.
• There must be documentation of patient cancellation or failure
to show for a visit.
• Evidence of coordination of care with other relevant behavioral
health providers and/or medical professionals must be
documented.
• Unresolved problems from previous visits must be addressed
and the outcomes documented.
• If safety or risk characteristics are identified, they must be
prominently documented and addressed during each visit.
• Phone conversations with persons relevant to treatment, e.g.,
referral sources, physicians, or parents, must be documented.
3-26 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/11/11)

Quality Improvement
Treatment Record
Documentation
(continued)
Medication Management
• Significant illnesses, clinical risks, and medical conditions are
to be clearly noted and revised periodically.
• Current medications prescribed by all prescribing physicians
must be listed. Dosages and dates of initial prescription and/or
refills must be documented.
• Evidence of informed patient consent for the receipt of
medication must be documented.
• Laboratory orders and results must be documented as well as
review of the results by the ordering physician. If abnormalities
are found, follow-up plans must be documented.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/11/11) 3-27

Chapter 4
Integrated Health Management
Table of Contents
Integrated Health Management................................................................................................ 4-3
Introduction............................................................................................................................4-3
Objectives ..............................................................................................................................4-3
Provider Contractual Obligations – Important Program Points............................................. 4-4
Integrated Health Management Decision Making .................................................................4-5
Utilization Management ............................................................................................................ 4-6
Purpose................................................................................................................................... 4-6
Goals ...................................................................................................................................... 4-6
Integrated Health Management Medical and Behavioral Health Clinical Staff ....................4-7
Medical Policy ............................................................................................................................ 4-8
Medical and Behavioral Health Policy Development............................................................4-8
Medical Policy and Behavioral Health Policy Manual.......................................................... 4-9
Prior Service Request Form................................................................................................. 4-10
High Technology Diagnostic Imaging Decision Support...................................................... 4-11
Overview..............................................................................................................................4-11
Pre-Certification/Authorization ............................................................................................. 4-14
Overview..............................................................................................................................4-14
Scope and Purpose ...............................................................................................................4-15
Decision Making and Notification Time frames ................................................................. 4-16
Definition of Urgent Request...............................................................................................4-17
Services Requiring Pre-Certification Utilization Management Pre-
Certification/Authorization Requirements............................................................................ 4-19
Overview..............................................................................................................................4-19
Inpatient & Residential Pre-Service Admission Requirements........................................... 4-19
Out-of-area Blue Plan Patients............................................................................................. 4-19
For Local Blue Cross Plan Patients ..................................................................................... 4-19
Where to Send Requests..........................................................................................................4-21
Inpatient Admissions ........................................................................................................... 4-21
Inpatient Pre-Certification/Authorization Requests.............................................................4-21
Appeals ................................................................................................................................4-22
On-site Concurrent Review..................................................................................................4-22
Compliance Audit .................................................................................................................... 4-23
Overview..............................................................................................................................4-23
Case & Disease Management.................................................................................................. 4-24
Overview..............................................................................................................................4-24
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12) 4-1

Integrated Health Management
Program Goals ..................................................................................................................... 4-24
Referrals to Case and Disease Management ......................................................................... 4-25
Case Management................................................................................................................ 4-25
Referrals to Commercial Case Management .......................................................................4-25
Referrals to Government Programs Case Management....................................................... 4-25
Disease Management ...........................................................................................................4-25
Disease States.......................................................................................................................4-26
Access Management Programs............................................................................................ 4-26
Focused Utilization Review ..................................................................................................... 4-28
Overview..............................................................................................................................4-28
Messages You May Receive................................................................................................ 4-29
Special Investigations ..........................................................................................................4-30
Documentation in the Medical Record .................................................................................. 4-31
Documentation Requirements.............................................................................................. 4-31
Overview..............................................................................................................................4-32
GA Modifier.........................................................................................................................4-33
Medical Referrals To Nonparticipating Providers............................................................... 4-34
Sample Waivers ................................................................................................................... 4-34
Upgraded/Deluxe Durable Medical Equipment (DME)......................................................4-35
DME Waiver Requirement .................................................................................................. 4-35
DME Claims Submissions ................................................................................................... 4-35
Sample DME Waiver...........................................................................................................4-36
4-2 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12)

Integrated Health Management
Integrated Health Management
Introduction As part of your participation agreement with Blue Cross and Blue
Shield of Minnesota (Blue Cross), you have agreed to comply with
Integrated Health Management programs administered by Blue
Cross and Blue Plus. These Integrated Health Management
programs are designed to ensure that the treatment members
receive is reimbursable according to the medical necessity
guidelines in their contracts. In addition, we review investigative
and new procedures/services for coverage determinations.
Integrated Health Management programs also ensure the most
cost-effective and appropriate use of the health care delivery
system.
These programs include:
Pre-Certification/Authorization of selected procedures,
services, supplies, and drugs
Preadmission Notification (PAN), Pre-Certification and
concurrent reviews for selected inpatient admissions
Case and Disease Management
Retrospective review of claims and medical records
To make utilization decisions, Blue Cross uses written utilization
review decision criteria based on sound clinical evidence. The
criteria used to evaluate an individual case is available, free of
charge, upon request for your review.
Objectives Integrated Health Management Programs are designed to:
Maximize the coordination of care and health outcomes.
Ensure appropriate and efficient utilization of health care
resources.
Promote efficient use of health care resources.
Define and agree upon appropriate standards of care.
Manage service for members with complex care coordination
needs.
Identify gaps in our members’ care and navigation of
resources.
Identification of members with conditions that will benefit
from self-care efforts, care intervention and communication.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12) 4-3

Integrated Health Management
Provider Contractual
Obligations –
Important Program
Points
The following points pertain to all of the Integrated Health
Management programs. Any medical necessity denial
determination may be discussed with a physician reviewer by
telephone.
Any services denied using Blue Cross’ medical necessity
guidelines cannot be billed to the member/patient unless you
have specifically notified the member/patient prior to the
service being rendered that the service is medically
unnecessary and will not be covered, and the member/patient
has agreed in writing to pay for the service. This applies to
investigative services as well as some non-covered services for
mental health. (Refer to Waiver Section.)
The Integrated Health Management process is a review for
medical necessity only. Payment for services is still subject to
all other terms of the member contract. Therefore, denials may
occur for preexisting conditions, benefit maximums,
coordination of benefits or riders in the member’s contract, that
supersede medical necessity.
We recommend that you utilize provider web self-service,
BLUELINE or contact provider services to verify coverage,
benefits, contract eligibility and limitations for all patients.
Service representatives will also verify which Integrated
Health Management procedures apply to a patient’s contract.
Providers will be held financially liable for services that are
determined to be not medically necessary during a review or an
audit process, even though pre-certification/pre-authorization
and/or admission review has been requested or is not
recommended.
4-4 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12)

Integrated Health
Management Decision
Making
Integrated Health Management
Integrated Health Management including utilization management
(UM) decision-making is based only on appropriateness of care,
service and existence of coverage. Blue Cross does not compensate
practitioners or other individuals conducting utilization review
decision-making activities for denials of coverage or service. Blue
Cross does not offer incentives to decision-makers to encourage
denials of coverage or service that would result in less than
appropriate care or underutilization of appropriate care and
services.
Blue Cross UM decision-making processes ensure that members
are not discriminated against in the delivery of health care services
consistent with the benefits covered in their health coverage plan
based on race, ethnicity, national origin, religion, sex, age, mental
or physical disability, sexual orientation, genetic information or
source of payment through the use of specific clinical criteria and
consideration of the individual needs of each case.
This statement exists to inform and remind providers, their
employees, their supervisors, upper management, medical
directors, UM directors or managers, licensed UM staff, and other
personnel and UM staff employed by participating providers, who
make utilization management decisions of this philosophy and
practice. This includes delegates conducting utilization
management services on behalf of Blue Cross.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12) 4-5

Integrated Health Management
Utilization Management
Purpose The purpose of the UM Program is to promote effective,
appropriate and efficient use of medical and behavioral health care
resources for our members.
UM is defined by the Utilization Review Accreditation Committee
(URAC) as “the evaluation of the necessity, appropriateness, and
efficiency of the use of health care services, procedures, and
facilities under the auspices of the applicable health benefit plan.”
IHM uses the UM program processes, procedures and criteria to
review and coordinate members’ benefits to enhance the
efficiency, affordability and quality of care.
The UM program is a set of continuously improving processes,
designed to both meet our member’s needs, as well as regulatory
and accreditation requirements. The UM program includes
processes for:
Identifying over and under utilization
Identifying members with complex health issues that may
benefit from case management
The collection and distribution of UM data
Goals The UM program purpose of promoting effective, appropriate, and
efficient use of health care resources is accomplished by adhering
to the UM processes described in this program. The program goals
are to:
Ensure objective and consistent utilization management
decision-making
Ensure that members have access to appropriate and timely
medical and behavioral health care across the provider network
Improve service and claims processes to provide optimal
handling of pre-service authorization and post-service payment
Ensure timely resolution of identified problems
Continually build and maintain collaborative relationships with
medical and behavioral health care providers
4-6 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12)

Integrated Health
Management Medical
and Behavioral Health
Clinical Staff
Integrated Health Management
IHM medical and behavioral health clinical staff is responsible for
the coordination of utilization management functions for eligible
members. Clinical staff is required to maintain an active
unrestricted health license in Minnesota. The IHM medical and
behavioral health clinical staff is permitted to approve requested
authorizations based on plan documents, policies, procedures, and
established medical and behavioral health clinical criteria.
Physicians or appropriately licensed peer reviewers make
necessary medical necessity denials.
Contractual benefits, medical necessity, appropriateness, and
individual needs are evaluated during the review process to
determine coverage of services. All requests for services that do
not meet medical necessity criteria are reviewed through the
physician peer review process.
UM decision-making is based only on appropriateness of care and
service, and existence of coverage. No financial incentive is
awarded to clinical staff for denying requests for service or based
on coverage decisions.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12) 4-7

Integrated Health Management
Medical Policy
Medical and Behavioral
Health Policy
Development
Medical and behavioral health policies are developed by the Blue
Cross and Blue Shield of Minnesota (Blue Cross) Medical and
Behavioral Health Policy Committee, which is comprised of
practicing physicians and providers representing a variety of
specialties in the local community and one Blue Cross
representative.
Blue Cross makes its determination of experimental, investigative
or unproven based upon a preponderance of evidence after the
examination of the following reliable evidence, none of which
shall be determinative in and of itself:
1. Whether there is final approval from the appropriate
government regulatory agency, if approval is required;
2. Whether there are consensus opinions and recommendations
reported in relevant scientific and medical literature, peerreviewed
journals, or the reports of clinical trial committees
and other assessment bodies; and
3. Whether there are consensus opinions of national and local
health care providers in the applicable specialty or subspecialty
that typically manages the condition as determined by a survey
or poll of a representative sampling of these providers.
The committee considers a number of additional factors when
evaluating each of the criteria. These factors include, but are not
limited to: quality of the available peer-reviewed medical
literature; safety, effectiveness, appropriateness of technology;
Blue Cross and Blue Shield Association requirements and Medical
Policies; and the relevant impact and consequences of coverage for
the technology (for example, patient, Blue Cross, ethical, societal,
legal).
A drug, device, medical treatment, diagnostic procedure,
technology or procedure for which reliable evidence does not
permit conclusions concerning its safety, effectiveness, or effect on
health outcomes. Blue Cross bases its decision upon an
examination of the following reliable evidence, none of which is
determinative in and of itself.
Drugs and devices cannot be lawfully marketed without the
approval of the U.S. Food and Drug Administration and approval
for marketing has not been given at the time the drug or device is
furnished.
4-8 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12)

Medical and Behavioral
Health Policy
Development
(continued)
Medical Policy and
Behavioral Health
Policy Manual
Integrated Health Management
The drug, device, diagnostic procedure, technology, or medical
treatment or procedure is the subject of ongoing Phase I, II, or III
clinical trials:
Phase I clinical trials determine the safe dosages of medication
for Phase II trials and define acute effects on normal tissue.
Phase II clinical trials determine clinical response in a defined
patient setting. If significant activity is observed in any disease
during Phase II, further clinical trials usually study a
comparison of the experimental treatment with the standard
treatment in Phase III trials. Phase III trials are typically quite
large and require many patients to determine if a treatment
improves outcomes in a large population of patients); or
Medically reasonable conclusions establishing its safety,
effectiveness or effect on health outcomes have not been
established. For purposes of this subparagraph, a drug, device,
diagnostic procedure, technology, or medical treatment or
procedure shall not be considered investigative if reliable
evidence shows that it is safe and effective for the treatment of
a particular patient.
Medical and behavioral health policies are available for your use
and review on the Blue Cross website at
providers.bluecrossmn.com. From this site, there are two ways to
access medical policy information depending on the patient’s Blue
Plan membership.
For Out-of-area Blue Plan Patients
1. Select Medical Policy Pre-Cert/Auth Router
2. Click Go.
You will be taken to the page where you select either medical
policy or pre-certification/prior authorization
3. Enter the patient’s three-letter alpha prefix (as found on their
member ID card)
4. Click Go.
Once you accept the requirements, you will be routed to the
patient’s home plan where you can access medical policy or precertification/pre-authorization
information.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12) 4-9

Integrated Health Management
Medical Policy and
Behavioral Health
Policy Manual
(continued)
Prior Service Request
Form
For local Blue Cross Plan Patients
1. Under the Tools and Resources, select “Medical Policy”
2. Read and accept the Blue Cross Medical Policy Statement
3. Select “View All Active Policies.” You have now navigated to
the Blue Cross Medical and Behavioral Health Policy Manual,
where there are several selections to assist with your inquiry.
The “What’s New” section identifies our latest new or
revised policies approved by Blue Cross’ Medical and
Behavioral Health Policy Committee at least 45 days ago.
These policies are now effective and providers should
begin following these policies immediately.
These policies also appear in the “Active Policy” section of
the Medical and Behavioral Health Policy Manual.
The “Upcoming Policies” section lists new or revised
policies approved by the Blue Cross Medical and
Behavioral Health Policy Committee. They are effective 45
days from the date they were posted to the “Upcoming
Policies” section of the Medical and Behavioral Health
Policy Manual.
The “Active Policy” section contains the entire list of
policies effective at the time of your inquiry.
Note: DHS programs have a separate section titled
“Coverage Guidelines for DHS Programs (MHCP
Manual).”
A sample of the Prior Authorization Request, form number F1676
is available on our website. The Transplant Prior Authorization
Request form number X16519 is available on our website.
For behavioral health, please refer to Prior Authorization-
Outpatient Mental Health and Prior Authorization-Chemical
Dependency.
4-10 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12)

Integrated Health Management
High Technology Diagnostic Imaging Decision
Support
Overview Blue Cross and Blue Shield of Minnesota and Blue Plus (Blue
Cross) have entered a relationship with Nuance for the Institute of
Clinical Systems Improvement (ICSI) sponsored HTDI automated
decision support program. This change could impact the processes you
currently follow today regarding data submission and precertification/pre-authorization
decision support services for HTDI.
Key process changes
Effective November 1, 2011, ordering providers are required to
use a decision support system as part of their process for
elective, outpatient HTDI procedures. This can be performed
either by Electronic Medical Record (EMR) integrated RadPort
software or the web-based version. Providers who choose to
use other programs should contact Blue Cross.
All providers must continue to follow Medical and Behavioral
Health Policies for selected HDTI procedures as summarized
in the section below both before and after November 1,
2011.
For specific questions about Nuance's RadPort tool, or to
schedule training and implementation of the tool, contact ICSI
at (952) 814-7067 or htdi@icsi.org
Imaging procedures included in the automated decision support
HTDI program
The new program covers the following elective, outpatient HTDI
procedures:
Computed tomography and angiography (CT/CTA) scans
Positron emission tomography (PET scans)
Magnetic resonance imaging and magnetic resonance
angiography (MRI/MRA) scans
Nuclear cardiology scans
Combinations of PET, CT, MRI, etc.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12) 4-11

Integrated Health Management
Overview (continued) Medical and Behavioral Health Policies relating to HTDI
Commercial Products
All providers must continue to follow current pre-certification/preauthorization
and investigative policies in the Medical and
Behavioral Health Policy Manual for commercial products. The
following procedures have coverage criteria, are subject to medical
review and continue to require the standard pre-certification/preauthorization
process as noted:
Computed tomography angiography (CTA) for evaluation of
coronary arteries
CT colonography (virtual colonoscopy) as a screening test for
colorectal cancer (pre-certification/pre-authorization required)
MRI of the breast (pre-certification/authorization required
EXCEPT in individuals with biopsy proven breast cancer).
Positron emission tomography (PET)
Minnesota Health Care Programs (MHCP)
All providers must continue to follow current pre-certification/preauthorization
and investigative policies in the Medical and
Behavioral Health Policy Manual for Minnesota Health Care
Programs (MHCP) as defined in your Provider Service Agreement.
The following procedures continue to require the standard precertification/pre-authorization
process:
MRI of the breast
CT colonography (virtual colonoscopy)
Computed tomography angiography (CTA) for evaluation of
coronary arteries, including coronary CT and EBCT for
calcium Scoring
PET scans
SPECT scans
Capsule endoscopy
4-12 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12)

Overview (continued) Non-Covered Procedures
Integrated Health Management
These procedures are not covered for either commercial or
Minnesota Health Care Programs (MHCP) members:
Computed tomography (CT) screening for coronary artery
disease
Full body CT scanning
Spiral CT screening for lung cancer
Members covered by the program
To date, this program includes the following Blue Cross lines of
business in the Minnesota service area and surrounding counties in
Wisconsin, South Dakota, North Dakota and Iowa (surrounding
counties are relevant only to contracting with providers, not with
location of members):
Blue Cross fully insured members
A limited number of Blue Cross self-insured Minnesota
members
Blue Plus subscribers enrolled in Minnesota Health Care
Programs(MHCP)
The HTDI program does not apply to any Medicare products,
BlueLink TPA, or FEP ®
The EMR integrated RadPort software or the web-based version
will display the member's name if they are included under the
HTDI program. (Blue Cross membership feeds to RadPort contain
only members who are part of HTDI program, so if the member is
not displayed in RadPort that member is not included.)
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12) 4-13

Integrated Health Management
Pre-Certification/Authorization
Overview The purpose of pre-certification/authorization is to review services
prior to being rendered to determine if the services are
contractually eligible and medically necessary. Medical policy
criteria and member contract language is used to assist in
determining if benefits are available for the requested service.
Certification/Authorization for a service, device or drug does
not in itself guarantee coverage, but notifies you that as
described, the service, device or drug meets the criteria for medical
necessity and appropriateness. Payment for services and/or
supplies Blue Cross approves in advance is based on the following
requirements: if the policy is in force the date the member receives
care, premiums have been paid, lifetime or benefit maximums
have not been exceeded, the condition is not subject to a
preexisting condition limitation period, and the procedure that is
authorized is the service and/or supply that is billed by the
provider. Deductibles, coinsurance, allowed amount and copayments
will apply.
The “pre-certification/authorization” section identifies various
services, procedures, prescription drugs, and medical devices that
require pre-certification/pre-authorization. Please note, commercial
(including BlueLink TPA) and MN Government Programs have
different pre-certification/authorization lists and requirements.
These lists are not exclusive to medical policy services only; they
encompass other services that are subject to precertification/authorization
requirements. For your convenience,
links to the “Commercial Forms,” “BlueLink TPA Forms,” CMS
and DHS criteria websites have also been provided.
The Blue Cross clinical reviewer uses local and national medical
policy, Medicare guidelines, MHCP Guidelines, behavioral health
criteria and member contract language to assist in determining if
benefits are available for the request. Criteria are determined by
the type of plan in which the member is enrolled. Authorization for
a service, device, or drug does not in itself guarantee coverage but
notifies you if the request meets the criteria for medical necessity
and appropriateness. The provider should always check with
customer service to make sure the member, or patient has contract
benefits and that the coverage is up to date.
We will evaluate your request for pre-certification and will make a
determination once all the necessary medical information is
received. Review decisions will be made and communicated
within required time frames as defined by state and federal law.
4-14 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12)

Integrated Health Management
Scope and Purpose These policies are applicable to all commercial and government
program products; medical, surgical, and behavioral health
services are included.
Benefit plans vary in coverage and some plans may not provide
coverage for certain services discussed in the medical policies.
Medicaid products may have additional policies and prior
authorization requirements, as well as some self and fully insured
plans. Coverage decisions are subject to all terms and conditions of
the applicable benefit plan, including specific exclusions and
limitations, and to applicable state and/or federal law.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12) 4-15

Integrated Health Management
Decision Making and
Notification Time
frames
(Electronic or written)
To ensure timely processing and assist us in meeting compliance
with state and federal guidelines, please submit precertification/authorization
requests at least 15 business days prior
to any elective services being rendered.
File Type Decision-Making Time frame Initial Notification Time frame
(Telephone Practitioner only) Follow-up Notification Time frame
(Members and Practitioners)
Pre-certification Request – Nonurgent:
Initial and Concurrent: Commercial: Within 10 business days* of receiving request, not to exceed 15
calendar days**.
Government Programs: Within 10 business days/14 calendar days, whichever is sooner. Within 1
business day* of making decision and within time frame. Commercial: Within 10 business days* of
receiving request, not to exceed 15 calendar days**.
Government Programs: Within 10 business days/14 calendar days, whichever is sooner
Pre-certification Request – Urgent Commercial: Within 72 hours of receiving request or as
expeditiously as the member's health condition warrants Government: Within 72 hours of receiving
request or as expeditiously as the member's health condition warrants. Same day as decision.
Commercial: Within 72 hours of receiving request or as expeditiously as the member's health condition
warrants. Government: Within 72 hours of receiving request or as expeditiously as the member's health
condition warrants.
Concurrent Review:
Urgent Within 24 hours of receiving request. Applicable to Commercial & Government Programs
business. Within 24 hours of receiving request. Within 24 hours of receiving request. Applicable to
Commercial & Government Programs business.
Post-service Request (Retrospective) Within 30 calendar days** of receiving the request.
Applicable to Commercial & Government Programs business. Within 30 calendar days** of receiving the
request. Within 30 calendar days** of receiving the request. Applicable to Commercial & Government
Programs business.
*Business day: Day in which Blue Cross is open for business, does not include weekends or holidays.
** Calendar day: Days in sequence on calendar, including weekends and holidays
4-16 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12)

Definition of Urgent
Request
The federal regulations define an urgent request as:
Integrated Health Management
Requires immediate action to prevent a serious deterioration of
a member’s health that results from an unforeseen illness or an
injury, or
Could jeopardize the ability of the individual to regain
maximum function based upon a prudent layperson’s
judgment, or
In the opinion of the treating physician, would subject the
individual to severe pain that cannot be adequately managed
without the treatment being requested. An urgent condition is a
situation that has the potential to become an emergency in the
absence of treatment.
Requests not meeting the conditions for an urgent request will be
considered nonurgent. Both urgent and nonurgent requests will be
reviewed and completed within current state and federal timelines.
For expedited requests, Blue Cross adheres to federal and state
requirements for decision-making time frames. Blue Cross uses the
following definitions to determine if a request is expedited:
For Commercial Plans
Requires immediate action to prevent a serious deterioration of a
member’s health that results from an unforeseen illness or an
injury, or
Could jeopardize the ability of the individual to regain maximum
function based upon a prudent layperson’s judgment, or
In the opinion of the treating physician, would subject the
individual to severe pain that cannot be adequately managed
without the treatment being requested. An urgent condition is a
situation that has the potential to become an emergency in the
absence of treatment.
Requests not meeting the criteria for the urgent definition for an
urgent request will be considered nonurgent. Providers submitting
the request will be notified by Blue Cross that the request does not
meet urgent criteria and will be managed according to nonurgent
criteria. Both urgent and nonurgent requests will be reviewed.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12) 4-17

Integrated Health Management
Definition of Urgent
Request (continued)
For Minnesota Government Programs
The attending health care professional believes that an expedited
determination is warranted when the standard decision time frame
may jeopardize the member’s health or ability to regain maximum
functioning.
An expedited determination is completed as the enrollee's medical
condition requires, but no later than 72 hours from the initial
request.
Requests not meeting the criteria for the urgent definition for an
urgent request will be considered nonurgent. Providers submitting
the request will be notified by Blue Cross that the request does not
meet urgent criteria and will be managed according to nonurgent
criteria. Both urgent and nonurgent requests will be reviewed and
completed within current state and federal timelines.
4-18 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12)

Integrated Health Management
Services Requiring Pre-Certification Utilization
Management Pre-Certification/Authorization
Requirements
Overview Medical and behavioral health policies are available for your use
and review on the Blue Cross website at
providers.bluecrossmn.com. From this site, there are two ways to
access medical policy information depending on the patient’s Blue
Plan membership.
Inpatient & Residential
Pre-Service Admission
Requirements
Out-of-area Blue Plan
Patients
For Local Blue Cross
Plan Patients
Note: Providers are required to report all inpatient admissions and
discharges to Blue Cross. Refer to “Where to Send
Requests” section.
Providers are required to report all inpatient admissions and
discharges to Blue Cross.
The member’s ID card has a number to call for precertification/pre-authorization
for inpatient admissions.
1. Under the Tools and Resources, select “Medical Policy”
2. Read and accept the Blue Cross Medical Policy Statement
3. Select “View All Active Policies.”
You have now navigated to the Blue Cross Medical and
Behavioral Health Policy Manual. Within in the manual, there are
several selections to assist with your inquiry.
1. Under the Tools and Resources, select “Medical Policy”
2. Read and accept the Blue Cross Medical Policy Statement
3. Select “View All Active Policies.”
You have now navigated to the Blue Cross Medical and
Behavioral Health Policy Manual. Within in the manual, there are
several selections to assist with your inquiry.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12) 4-19

Integrated Health Management
For Local Blue Cross
Plan Patients
(continued)
The “What’s New” section identifies our latest new or revised
policies approved by Blue Cross Medical and Behavioral
Health Policy Committee at least 45 days ago. These policies
are now effective and providers should begin following these
policies immediately. These policies also appear in the “Active
Policy” section of the Medical and Behavioral Health Policy
Manual.
The “Upcoming Policies” section lists new or revised policies
approved by the Blue Cross Medical and Behavioral Health
Policy Committee and are effective 45 days from the date they
were posted to the “Upcoming Policies” section of the Medical
and Behavioral Health Policy Manual.
The “Active Policy” section contains the entire list of policies
effective at the time of your inquiry.
Note: DHS programs have a separate section titled “Coverage
Guidelines for DHS Programs (MHCP Manual).”
The “Pre-Certification/Authorization” section identifies
various services, procedures, prescription drugs, and medical
devices that require pre-certification/authorization. Please note,
Commercial (including BlueLink TPA) and MN Government
Programs have different pre-certification/authorization lists
and requirements. These lists are not exclusive to medical
policy services only; they encompass other services that are
subject to pre-certification/authorization requirements. These
lists are maintained on the provider website.
4-20 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12)

Where to Send Requests
Integrated Health Management
Inpatient Admissions Providers are required to report all inpatient admissions and
discharges to Blue Cross.
Inpatient Pre-
Certification/Authoriza
tion Requests
Commercial
Enter admissions through our PWSS portal and for *Services
requiring pre-certification providers should call our provider
services center at 1-800-262-0820 or (651) 662-5200.
(* Services that require pre-certification are: FEP, newborn,
Mental Health and Chemical Dependency/Detox, Inpatient Acute
Rehab and Long Term Acute Care admissions)
Government Programs
Enter admissions through our PWSS portal and for *Services
requiring pre-certification providers should call our provider
services center at 1-800-262-0820 or (651) 662-5200.
(* Services that require pre-certification are: Newborn, Mental
Health and Chemical Dependency/Detox, Inpatient Acute Rehab
and Long Term Acute Care admissions)
Commercial
Blue Cross and Blue Shield of Minnesota
P.O. Box 64265 Attn: Pre-certification
St. Paul, MN 55164-0265
Fax: (651) 662-2810
Government Programs
Blue Cross and Blue Shield of Minnesota
Attn: Pre-certification
P.O Box 64255
St. Paul, MN 55164-0255
1-866-800-1665
Fax: (651) 662-4022
Transplants (Commercial and Government Program requests):
Blue Cross and Blue Shield of Minnesota
Attn: Transplant Coordinator
Route R472
PO Box 64179
St. Paul, MN 55164-0179
Fax: (651) 662-1624
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12) 4-21

Integrated Health Management
Appeals Information regarding appeals for denied pre-certification requests
can be found in the Appeals section (Chapter 10) of this manual.
On-site Concurrent
Review
Blue Cross conducts on-site inpatient concurrent review at select
MN hospitals. The goal of the on-site clinical program is to:
Identify members who have been admitted, discharged to home
or to another level of care.
Understand length of stay of member who may be at risk of
hitting outlier status.
Assist members with transition of care needs and bridge the
gap between facility and community.
Engage members in our plan-based case/disease management
activities sooner and more reliably.
Inpatient concurrent review will continue to expand. Although we
will not be on-site at each hospital or inpatient facility, we may be
in contact with you telephonically.
Note: Preadmission notification or certification is required by Blue
Cross. Refer to “Where to Send Requests” for details on
how and where to submit a hospital/inpatient admission.
4-22 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12)

Compliance Audit
Integrated Health Management
Overview Your provider services agreement includes certain quality
assurance requirements. Pursuant to this agreement, Blue Cross
may conduct audits to evaluate a provider’s compliance with
medical necessity guidelines and standards of practice in the
community. Such an audit could include post-service claims
review, which may result in provider liability if the care is
determined to be not medically necessary or medically
inappropriate.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12) 4-23

Integrated Health Management
Case & Disease Management
Overview Mission Statement
Integrated Health Management (IHM) combines historically
fragmented Disease and Case Management services to provide a
whole person approach to improving member health, working with
members who are facing chronic, complex, catastrophic injuries,
illness or diseases.
IHM clinicians work collaboratively with members, providers, and
the community to promote optimal health, and coordinate access to
services across the continuum of care that is holistic, seamless and
easily accessible.
Clinicians
Licensed Dedicated Nurses/Clinicians, using a collaborative
process, advocate, assess, plan, implement, coordinate, monitor
and evaluate options and services to meet an individual’s specific
health care needs through education and communication of
available resources to promote high quality, cost effective
outcomes for members with medical and behavioral conditions that
require ongoing or intermittent care. Clinicians are required to
maintain an active unrestricted health license in Minnesota.
Program Goals Maximize optimal health and functional outcomes.
Identify gaps in care.
Reach out to the members with the greatest need and educate
them about their condition.
Support and encourage individual accountability for health and
wellness (self-care management).
Help members coordinate their needs and navigate services in
the health care system.
Tailor interventions and outreach to promote the appropriate
use of health care services.
Improve member satisfaction with the health plan and health
care system.
4-24 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12)

Referrals to Case and Disease Management
Case Management Maximize optimal health and functional outcomes
Referrals to
Commercial Case
Management
Referrals to
Government Programs
Case Management
Identify gaps in care
Integrated Health Management
Reach out to the members with the greatest need and educate
them about their condition
Support and encourage individual accountability for health and
wellness (self-care management)
Help members coordinate their needs and navigate services in
the health care system
Tailor interventions and outreach to promote the appropriate
use of health care services
Improve member satisfaction with the health plan and health
care system
A referral can be made by contacting the case management support
staff at (651) 662-5520 and toll free at 1-888-878-0139 extension
25520.
A referral to case management can be made by calling
(651) 662-5540, or toll free at 1-800-711-9868.
Please contact Government Programs Case Management when you
have a patient who may need additional supportive services, such
as a Restricted Recipient referral.
Disease Management Disease management is a multidisciplinary, continuum-based
approach to health care delivery that proactively identifies
populations who have or are at risk for, chronic medical and
behavioral health conditions. Disease management supports the
practitioner-patient relationship and plan of care, emphasizes the
prevention of exacerbation and complications using cost-effective,
evidence-based practice guidelines and patient empowerment
strategies such as education and self-management. The process of
disease management evaluates clinical, social/humanistic and
economic outcomes with the goal of improving overall health of
the whole person.
Members who receive disease management services receive
support from a dedicated clinician, who assists in facilitating the
health of the whole person, not just their individual condition.
*Services are offered to members, participation is optional.
* Member eligibility for disease management is determined by the
member/subscriber contract.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12) 4-25

Integrated Health Management
Disease States Commercial Government Programs
Access Management
Programs
Asthma
Coronary Artery Diseases (CAD)
Chronic Kidney Disease (CKD)
Chronic Obstructive Pulmonary Disease (COPD)
Depression
Diabetes
Heart Failure
Low Back Pain
Oncology
In addition to the above conditions, Blue Cross also offers a
prenatal support program (Healthy Start ® Prenatal Support) to
eligible members. Please contact customer service to determine if a
member is eligible.
A dedicated nurse or clinician may contact your office for
assistance with a Blue Cross member’s needs. They may also send
you a letter including member goals and/or gaps in care to inform
you on what we are working with the member to advance their
health care needs. We look forward to working with our member’s
practitioners to make a healthy difference in our member’s health.
Access management is a specialized program for fully insured
commercial and Minnesota Health Care Program members.
Blue Plus members include members with coverage through:
Prepaid Medical Assistance Program Services for Persons
Under Age 65 (PMAP and MinnesotaCare Program Services
(MNCare). MHCP also refers to this program as the Restricted
Recipient Program.
Restrictions of Medicare services are not allowable per DHS
contract 2.119. For members who are on Medicare integrated
product (SecureBlue SM [HMO SNP]), it is permissible to restrict
Medicaid-only services. Blue Plus is not able to restrict Part D
drug coverage and implement physician sole prescribers for public
program members with Medicare (MSC+). If a MSC+ member is
not Medicare eligible, restriction is permissible.
4-26 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12)

Access Management
Programs (continued)
Integrated Health Management
Access management members/restricted recipients are members
who have used services at a frequency or amount that is not
medically necessary and/or who have obtained services in an
inappropriate manner.
Access management specialists in Integrated Health Management
review members’ medical and pharmacy claims for potential
restriction. Members who meet the access management program
criteria are assigned to a specific physician for the primary care
needs who, in turn, will coordinate all their care and medication
needs. The member will also be assigned to a single pharmacy and
a single hospital. Access to specialty care may be discussed with
the access manager assigned to the member. Access management
program restriction is for 24 months.
As a provider, you need to verify if a member has a restriction
before providing services.
If you provide services to a member enrolled in this program and
you are not the assigned physician, pharmacy or hospital claims
payment may be impacted.
Eligible services provided to a member in the access management
program will be reimbursed only when one of the following
criteria is met:
The service is provided by the member’s assigned provider.
The service is of a provider type or type of service that is not
listed as needing access management.
This includes durable medical equipment (DME), home care,
ambulance services, mental health or chemical health services.
Access management specialists will refer suspect cases to the
special investigation unit (SIU) as needed.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12) 4-27

Integrated Health Management
Focused Utilization Review
Overview Focused utilization review programs contribute to our goals of
containing health care costs by assuring that services are contract
benefits and appropriate. Blue Cross systematically monitors
services of providers for patterns of overuse, underuse, misuse and
abuse in addition for obsolete or questionable practices.
Blue Cross has data warehousing and software programs that look
for patterns outside established norms. The analysts review
medical records and work with providers to resolve questions on
coding, benefits and medical necessity. On-site audits, using a
sample of up to the last three years of claims history may be
performed. Prompt response to medical records requests will speed
up processing of claims under review. Claims are denied as
provider liability if the necessary information is not received
within 14 calendar days.
4-28 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12)

Messages You May
Receive
Integrated Health Management
The following message appears on the Statement of Provider
Claims Paid to tell you that we did not receive the information
needed to review the claim:
We cannot continue processing of this claim because the
medical information we requested has not been received. We
will reprocess your claim upon receipt of the requested
information.
During utilization review, claims are screened for medical
necessity. Peer review agents or consultants deny claims only after
careful evaluation. Slightly longer processing time is required for
claims that must go through the utilization review process. The
following messages appear on the Statement of Provider Claims
Paid for utilization review denials:
This contract does not cover charges for treatment, services, or
supplies which do not meet our criteria for medical necessity or
are not normally provided for the treatment of this condition as
determined by our medical staff and/or an independent health
care professional reviewer.
These charges are not covered because this contract does not
allow services from a provider performing this type of health
care.
This service and related charges are considered investigative
and are not covered according to this contract. Our Medical
Policy Committee continually reviews medical procedures in
order to determine the investigative status of this and other
services.
These charges are not allowed because there was no
documentation in the medical records to support this level of
care.
Participating providers agree not to bill the member for any
services Blue Cross determines to be not medically necessary or
investigative. Medical necessity denials can be appealed within 30
days from the date you are notified. We request that you submit
written appeals outlining the issues and ATTACH supporting
documentation such as medical records, operative reports, and any
medical information documenting unusual circumstances at the
time of the request.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12) 4-29

Integrated Health Management
Special Investigations Blue Cross actively investigates possible fraudulent claims
submissions from both members and providers. Fraud and abuse
investigations conducted by our special investigations department
are among the most thorough in the industry. Inconsistent charges,
forged or altered charges, or services billed but never rendered are
just a few examples of inappropriate practices that we may verify
when conducting our investigation. Our investigation process may
include, but is not limited to, record requests, audits, and survey
letters.
Blue Cross often conducts our investigations and criminal
proceedings in collaboration with outside agencies such as the
state attorney general’s office, the FBI, postal inspectors, or local
authorities. Our goal is to protect Blue Cross members and
providers from losses due to fraudulent acts.
Information about any person’s inappropriate use of a Blue Cross
policy, member ID card, or questionable billing practices should
be reported by calling our fraud hot line. The phone number is
listed in Chapter 1 — At Your Service. You may remain
anonymous if you wish.
4-30 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12)

Documentation in the Medical Record
Documentation
Requirements
Integrated Health Management
To avoid denials for medical necessity, the patient’s medical
record must contain certain pertinent information that may be
subject to our review. The Centers for Medicare and Medicaid
Services (CMS) in conjunction with the American Medical
Association (AMA) has developed guidelines for the medical
documentation necessary to support a given level of evaluation and
management service. Blue Cross adopted these guidelines to
ensure that our members receive quality care and that the services
are consistent with the health plan coverage provided.
The general guidelines are listed below:
The medical record should be complete and legible.
The documentation of each patient encounter should include:
reason for the encounter and relevant history, physical
examination findings and prior diagnostic test results;
plan of care; and
date and legible signature of the practitioner.
If not documented, the rationale for ordering diagnostic and
other ancillary services should be easily inferred.
Past and present diagnoses should be accessible to the treating
and/or consulting physician.
Appropriate health risk factors should be identified.
The patient’s progress, response and changes in treatment, and
revision of diagnosis should be documented.
The CPT/HCPCS and ICD-9-CM codes reported on the health
insurance claim form or billing statement should be supported
by the documentation in the medical record.
Charge slips, super bills, travel cards, or office ledgers are not
considered supporting documentation for services provided to a
patient.
Use of the term IBID (same as above) and/or the use of quotation
marks to replace or repeat previously documented information is
not acceptable. All information must be in date-sequence order.
Services not documented as indicated above are not covered by
Blue Cross. Patients are not financially liable for services that are
denied for inadequate documentation.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12) 4-31

Integrated Health Management
Overview Per your provider service agreement, you may not bill:
Any member for medically unnecessary or investigative
services.
Prepaid Medical Assistance Program (PMAP) and
MinnesotaCare members for services that are not covered at
your office, but may be covered if the member went to another
provider.
You may bill the patient only if the following conditions are met:
The patient is notified prior to the service being rendered that
the service is not covered, etc.
The member agrees, by signing a waiver, to pay for the service.
In addition, you should not direct your fee-for-service members to
nonparticipating providers (Refer to Referrals to Nonparticipating
Providers).
One of the DHS regulations includes enrollee rights to notification
of non-covered services. General signed statement information is
included in the Blue Cross Provider Policy and Procedure
Manual, Chapter 6.
The signed statement is allowed only when the service provided is
a non-covered service, and must be:
Specific to the procedure/service (including the cost)
Specific to a date of service
Signed and dated by the enrollee for each date of service
If the signed statement is not signed by the Public Programs
enrollee prior to the service, then according to DHS rules, the
enrollee cannot be billed for the service. This includes services that
are investigative, not medically necessary, or excluded from
coverage under the contract. You may bill an enrollee for noncovered
services only when Minnesota Health Care Programs
(MHCP) never covers the services and only if you inform the
enrollee before you deliver the services that he/she would be
responsible for payment. If MHCP normally covers a service but
the enrollee does not meet coverage criteria at the time of the
service, the provider cannot charge the enrollee and cannot accept
payment from the enrollee.
For example, if an enrollee did not receive a referral for a service
that required one, the service is not eligible for a signed statement;
and, the provider cannot bill the member for the service.
4-32 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12)

Integrated Health Management
Overview (continued) When submitting claims, indicate with a –GA in box 24D modifier
those services that have a valid signed statement on file.
We do not consider blanket (nonspecific) waivers sufficient
notice to meet the patient notification requirements in your
provider services agreement. The waiver must be dated and
must specifically identify the procedure or service. The waiver
must also advise the patient that he or she would not be liable
for these charges unless the waiver is signed.
GA Modifier Use the -GA modifier in field 24D of the CMS-1500 form to
indicate:
you have notified a patient that a specific service has been
determined by Blue Cross to be investigative or not medically
necessary, and
those services will most likely not be covered under the
member’s contract.
After this notice, and prior to receiving the services, the patient
must have agreed in writing that charges incurred will be the
patient’s liability.
The use of this modifier will result in allowed amounts related to
these services being reported in the patient responsibility column
of your provider remittance.
Note: The -GA modifier should not be used routinely on all of
your claims submittals. Inappropriate use of the -GA
modifier may result in an audit of your files and possible
payment adjustments.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12) 4-33

Integrated Health Management
Medical Referrals To
Nonparticipating
Providers
Blue Cross participating providers are required to direct their feefor-service
patients to other participating providers, including
anesthesiologists, radiologists, pathologists and surgical assistants.
Directories of participating providers are available upon request by
contacting provider services. Many times the member will have
reduced benefits and higher patient responsibility when using
nonparticipating providers.
Directing patients to nonparticipating providers may be necessary
in the following situations:
medical emergency
participating providers are not available within certain
geographic areas
quality of care or specialty care requires use of a
nonparticipating provider
Note: This is for Blue Cross fee-for-service contracts. Use the
Referral Network directory available on our website for
Blue Plus managed care referrals. Typically, the member
will receive the highest level of their benefits when
receiving a referral for those services that require a referral.
For complete information on Government Programs
requirements, please refer to Chapter 3 in the Blue Plus
Provider Manual.
If it is necessary to refer to a nonparticipating provider, the
participating physician must give the patient advance,
written notification that the referral is to a nonparticipating
physician. Once notice is given, the patient is responsible for
any increased liability if he or she decides to schedule the
service. If the patient is not properly informed, the provider
making the referral to a nonparticipating provider will be
liable for increased costs incurred by a patient.
Sample Waivers A sample waiver for use in your office is available on our website.
The waivers include the information required in order for you to
hold the member financially liable for services. The waiver should
be incorporated into your usual business forms and should be
customized to include your business letterhead.
4-34 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12)

Upgraded/Deluxe
Durable Medical
Equipment (DME)
DME Waiver
Requirement
DME Claims
Submissions
Commercial Business
Integrated Health Management
Participating durable medical equipment (DME) suppliers may bill
members for an equipment upgrade or deluxe charge if a waiver is
on file and the DME charges are billed correctly to Blue Cross. We
continue to reimburse for medically necessary standard DME.
Government Business
Participating durable medical equipment (DME) suppliers may bill
members for an equipment upgrade or deluxe charge if a waiver is
on file and the DME charges are billed correctly to Blue Cross.
Participating DME suppliers must obtain a signed, written waiver
from the member that includes the cost for the deluxe features or
upgrade. The waiver must also state the following:
the standard piece of equipment or least costly alternative
offered to the member,
the member is aware and agrees that Blue Cross will only pay
the standard allowance, and
the member will be responsible for the deluxe or upgrade
charge in addition to his or her contractual obligation.
This waiver must be kept on file at your office. If a precertification/authorization
are required for the item being provided,
please send the waiver form along with your request. For all
services that do not require a pre-certification/authorization, do
not send it to Blue Cross. We do, however, reserve the right to
see it.
Two lines of service must be billed. The first line will include the
DME HCPCS code and the standard charge for the equipment. The
second line must include the same DME HCPCS code with the -
GA modifier (waiver of liability statement on file) and the upgrade
or deluxe charge. For example:
E0202 -- $550.00 (standard charge that will be subject to
standard allowance and reductions)
E0202 GA -- $150.00 (deluxe/upgrade charge that will be
denied as member liability)
The -GA modifier must be submitted as the first modifier on the
second service line. Other applicable modifiers, such as -NU
(Purchase), should be submitted on the first service line.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12) 4-35

Integrated Health Management
Sample DME Waiver A sample waiver for use in your office is available on our website.
The waiver includes the information required in order to hold the
member financially liable for deluxe features or upgrades to a
durable medical equipment purchase. The waiver should be
incorporated into your usual business forms and customized to
include your business letterhead.
4-36 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12)

Table of Contents
Chapter 5
Health Care Options
Member ID Cards/Health Coverage Options.......................................................................... 5-3
Fully Insured Groups .............................................................................................................5-3
Self-Insured Groups...............................................................................................................5-3
Member ID Cards ..................................................................................................................5-4
Member ID Card Conversion.................................................................................................5-4
Helpful Tips ...........................................................................................................................5-5
Verify Identity of Cardholder ................................................................................................5-5
Blue Cross and Blue Shield of Minnesota Coverage Options................................................ 5-6
Overview................................................................................................................................5-6
Aware Gold ® ..........................................................................................................................5-6
Aware Gold Limited ..............................................................................................................5-6
Aware PPO.............................................................................................................................5-6
Blue Selections....................................................................................................................... 5-7
Options Blue HRA/HSA........................................................................................................5-7
Comprehensive Major Medical..............................................................................................5-7
Double Gold...........................................................................................................................5-8
Freedom 1-2-3........................................................................................................................5-8
Simply Blue SM ........................................................................................................................5-8
Personal Blue SM .....................................................................................................................5-8
GoBlue ...................................................................................................................................5-8
InstaCare ................................................................................................................................5-8
Medicare Supplemental Plans................................................................................................5-9
Medicare Basic Blue ® ..........................................................................................................5-10
Extended Basic Blue ® ..........................................................................................................5-10
Senior Gold SM ......................................................................................................................5-11
Platinum Blue SM (Cost)........................................................................................................ 5-12
MedicareBlue PPO (Regional PPO) ....................................................................................5-13
MedicareBlue Rx (PDP) ......................................................................................................5-14
Guidelines for Determining Submissions to Medicare or Blue Cross.................................5-15
Inquiries and Claims Platinum Blue (Cost) .........................................................................5-15
Blue Plus Coverage Options.................................................................................................... 5-19
Comprehensive Plan ............................................................................................................ 5-19
Preferred Gold SM ..................................................................................................................5-19
Triple Gold...........................................................................................................................5-19
Medicare Select Product ......................................................................................................5-19
Minnesota Senior Health Options (MSHO) / Secure Blue (HMO) .....................................5-20
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10) 5-1

Health Care Options
Prepaid Medical Assistance Program (PMAP), and Minnesota Senior Care Plus (MSC+) /
Blue Advantage....................................................................................................................5-21
MinnesotaCare Program ...................................................................................................... 5-22
Federal Employee Program .................................................................................................... 5-23
Federal Employee Program (FEP).......................................................................................5-23
Provider Statements .............................................................................................................5-23
Benefit Changes...................................................................................................................5-23
BlueLinkTPA .............................................................................................................................. 5-24
Healthy Start ® Prenatal Support............................................................................................ 5-25
Healthy Start ® Prenatal Support........................................................................................... 5-25
Delta Dental .............................................................................................................................. 5-26
History.................................................................................................................................. 5-26
Inquiries ...............................................................................................................................5-26
MII Life, Incorporated ............................................................................................................ 5-27
History..................................................................................................................................5-27
Products and Services ..........................................................................................................5-27
Prime Therapeutics LLC......................................................................................................... 5-28
History..................................................................................................................................5-28
Formularies ..........................................................................................................................5-28
Workers’ Compensation, No-Fault Auto & Subrogation .................................................... 5-29
Overview..............................................................................................................................5-29
Workers' Compensation, No-Fault Auto & Subrogation.....................................................5-29
Networks ................................................................................................................................... 5-34
Blue Cross (Aware)..............................................................................................................5-34
Select Networks ...................................................................................................................5-34
Blue Plus ® ............................................................................................................................5-34
BlueCard ® ............................................................................................................................5-34
Blue Distinction Centers ® ....................................................................................................5-34
Blue Precision ® ....................................................................................................................5-34
Accord Network...................................................................................................................5-34
Value Network.....................................................................................................................5-34
5-2 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10)

Member ID Cards/Health Coverage Options
Health Care Options
Fully Insured Groups Blue Cross and Blue Shield of Minnesota and Blue Plus (Blue
Cross) fully-insured contracts are available for employers that
select our standard benefits. The employer can choose the
deductible/coinsurance and copay amounts.
Fully insured contracts generally:
• offer consistent benefit options
• follow state mandates
• follow federal mandates
• have standard member identification (ID) cards
• are regulated by the Department of Commerce (fee-for-service)
or the Department of Health (managed care)
Self-Insured Groups We also administer self-insured contracts in which the employer
selects the benefits and assumes all or part of the financial risk.
These may also be referred to as ASOs (Administrative Services
Only). Self-insured contracts generally:
• offer many contract benefit options
• are not required to follow state mandates
• follow federal mandates
• have member ID cards that may not be standard and may
include the employer name and/or logo
Patients who belong to self-insured groups administered by Blue
Cross are to be treated as any other member for purposes of the
provider contract. Because your office must bill us directly for
these patients, it is important to check the back of the member ID
card to see if we are listed as the administrator of the health plan.
The front of the card may have the company’s plan name.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10) 5-3

Health Care Options
Member ID Cards Your patient’s member ID card contains information that is
essential for claims processing. We recommend that you look at
the member’s ID card at every visit and have a current copy of the
front and back of the card on file. There is a sample of some of the
member ID cards issued at Blue Cross on our website. Not all of
the following information is found on each member ID card:
Member ID Card
Conversion
• name of the plan
• member’s ID number including alpha prefix
• member’s name and group number
• primary care clinic (PCC) name – for managed care plans only
• Blue Shield plan code
• Blue Cross plan code
• prescription coverage
• copay for prescription drugs
• copay for office visits
• dependent-coverage indicator
• claims submission information
Blue Cross and its affiliates converted member identification
numbers from Social Security numbers as of December 31, 2004.
Members from the following Blue Cross lines of business will
retain their original identification number:
• Federal Employee Program - Identification numbers are not
the member’s social security number and are assigned by the
federal government.
• Minnesota government programs, including Prepaid
Medical Assistance Program and Minnesota Care -
Identification numbers are not the member’s social security
number, they being with an “8”.
• Workers’ Compensation - The Minnesota Department of
Labor and Industry requires the use of social security numbers
for anyone who has ever filed a work compensation claim.
5-4 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10)

Health Care Options
Helpful Tips • Ask members for their current member ID card and regularly
obtain new photocopies (front and back) of the member ID
card. Having the current card will enable you to submit claims
with the appropriate member information (including alpha
prefix) and avoid unnecessary claims payment delays.
• Check eligibility and benefits by using provider web selfservice,
BLUELINE or call 1-800-676-BLUE (2583) and
provide the alpha prefix.
• If the member presents a debit card (stand-alone or combined),
be sure to verify the copayment amounts before processing
payment.
• Please do not use the debit card to process full payment
upfront. If you have questions about the debit card processing
instructions or payment issues, please contact the debit card
administrator’s toll-free number on the back of the card.
Verify Identity of
Cardholder
We recommend that you verify the identity of Blue Cross
cardholders by asking for additional picture identification.
Identification numbers and group numbers must be submitted
correctly on electronic or paper claims in order for us to identify
the patient.
If you suspect fraudulent use of a member ID card, please call our
fraud hot line at (651) 662-8363. You may remain anonymous.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10) 5-5

Health Care Options
Blue Cross and Blue Shield of Minnesota Coverage
Options
Overview Blue Cross offer a wide variety of health coverage options. A
summary of those benefit options available to individuals and
groups follows in this chapter. All benefits are subject to the terms
of the member’s contract and certificate.
Please use provider web self-service, BLUELINE or provider
services to identify your patient’s eligibility and benefits.
Aware Gold ® Aware Gold is Blue Cross’ premier health plan. When using
participating providers, Aware Gold members usually receive 100
percent coverage for everything from preventive care, such as
annual physical examinations and lab and x-ray services, to
hospital inpatient services. Office visit copays may apply.
Members may choose to see specialists without referrals. If
members select out-of-network providers for non-emergency care,
deductibles and coinsurance may apply.
Aware Gold Limited Aware Gold Limited, a companion plan to Aware Gold, covers a
wide range of medical services from routine office visits to major
surgery, including chiropractic, mental health, and substance abuse
treatment. Aware Gold Limited members receive the highest level
of benefits when they see a network provider, do little or no
paperwork, and have coverage outside the network, anywhere in
the world. Under this plan, members pay a modest portion of their
health care costs in the form of a copay or coinsurance for many
services. An annual deductible applies only to certain services
from out-of-network providers.
Aware PPO Aware PPO is a fully insured open access product. Attractive to
groups that have members headquartered in Minnesota with a
concentrated population of employees also living in other
geographical areas. This plan covers eligible medial services, such
as inpatient and outpatient hospital services and doctor visits, at a
percentage after the deductible. Preventive care and well child
visits are covered at 100 percent under this plan.
Several calendar-year deductibles and out-of-pocket maximum
options are available.
Once the deductible has been met, Aware PPO pays a percentage
of the allowed amount for all eligible expenses, up to an
established out-of-pocket maximum. If eligible expenses during a
calendar year exceed the out-of-pocket maximum, Aware PPO
pays 100 percent of the allowed amount through the end of that
calendar year.
5-6 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10)

Health Care Options
Blue Selections Benefit plans that use the Blue Precision network of tiered
providers based upon quality of care and cost effective care.
Members receive the highest level of benefits by utilizing
providers in Tier 1.
Options Blue HRA/HSA Options Blue is the suite of consumer-directed health care
solutions. The components of Options Blue are a high-deductible
open access health plan (CMM or PPO), alongside an account that
is funded by the employer or employee, or both, that helps pay for
eligible out-of-pocket expenses (please note that HRAs can only
be funded by the employer). In most cases, any dollars that are
unused in the account at the end of the benefit year will roll over
and be added to new dollars in the next benefit year. The dollars
can be used to help pay for future out-of-pocket health care
expenses. Additionally, the Blue Cross Health Support member
health improvement tools (including Dedicated Nurse support,
Healthy Start and 24-Hour Nurse Advice Line) add to the overall
value of the product.
Comprehensive Major
Medical
From a health plan perspective, this plan works like any other
high-deductible health plan. Members are responsible for paying
providers for services that are not paid by the health plan.
Available account funds can be used by members to pay their
provider(s) for eligible care not reimbursed by the health plan.
Employers have an option to allow employees to have account
funds go directly to the provider. Providers will receive a check
directly from SelectAccount ® , the account administrator.
The Comprehensive Major Medical (CMM) plan is designed for
employer groups and individuals who are willing to pay a small
portion of their medical bills and still receive protection against the
costs of major illness or injury. This plan covers eligible medical
services, such as inpatient and outpatient hospital services, at a
percentage after a deductible. Preventive Care and well-child care
is covered at 100 percent under this plan.
Several calendar-year deductible and out-of-pocket maximum
options are available. Generally, the higher the deductible, the
lower the cost for comprehensive coverage.
Once the deductible has been met, CMM pays a percentage of the
allowed amount for all eligible expenses, up to an established outof-pocket
maximum. If eligible expenses during a calendar year
exceed the out-of-pocket maximum, CMM pays 100 percent of the
allowed amount through the end of that calendar year.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10) 5-7

Health Care Options
Double Gold Double Gold is a self-insured fee-for-service plan administered by
Blue Cross. Members have the freedom to see participating doctors
of their choice, however, the provider network for chiropractic and
behavioral health care may be limited depending on the employer
group. Office visit copays may apply.
Freedom 1-2-3 Is a new low-cost plan designed especially for employer groups
with 2-50 members? There is no coverage for certain mandated
benefits like chiropractic, mental health care, infertility and
bariatric surgery. This plan has a low deductible, with no office
visit copays. It includes generous upfront benefits for:
• One preventive care visit and one eye exam each year
• Two doctor’s office or urgent care visits each year
• Three retail health clinic visits each year
The group has the option to choose one of two networks. The
statewide Accord network or, in the 11-county metro area, our new
Value network.
Simply Blue SM Simply Blue offers essential health care coverage. The plan is
single coverage only ages 19-64. This plan offers three deductible
options, two drug options, and office visit copays. Substance abuse
coverage is optional. This plan offers the statewide Accord
network.
Personal Blue SM Personal Blue is a comprehensive major medical Individual plan
with some upfront coverage for office and retail health clinic office
visits and generic drug copay. There are a variety of deductible
options for members to choose from. This plan has family
coverage. Substance abuse coverage is optional. This plan offers
the statewide Accord network.
GoBlue GoBlue is our lowest cost plan that takes care of major expenses.
There are four deductible options and offers an urgent care and
generic drug copay. This plan is single coverage only for ages 19
through 64. This plan offers the statewide Accord network.
InstaCare InstaCare is our short-term coverage plan that offers immediate
protection. This plan does not cover preexisting conditions. There
are three deductible options to choose from and three contract term
durations – 30 day, 60 day, or 90 day.
5-8 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10)

Medicare
Supplemental Plans
Health Care Options
Blue Cross offers and has a variety of Medicare supplement plans.
Medicare supplement plans are designed to help fill the gaps in
Medicare coverage. Blue Cross has several Medicare supplement
plans that are no longer open for enrollment, however, members
who had signed up previous to plan closure are eligible to keep
their plan.
As of June 2006, Blue Cross currently has two Medicare
Supplement plans open for enrollment by individuals (as opposed
to employer groups), Basic MedicareBlue and Extended Basic
Blue and one Medicare Select plan, Senior Gold.
Under these plans, Medicare is the primary payer. Claims must be
submitted to Blue Cross with a copy of the Medicare Remittance
Advice (RA) form.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10) 5-9

Health Care Options
Medicare Basic Blue ® Medicare Basic Blue is our low-cost Medicare Supplement plan.
Members can enroll in the base plan and then select from a number
of additional coverage options to suit their needs.
The base plan for Medicare Basic Blue covers the Medicare
coinsurance for Part A and B, but does not cover the annual
deductibles. When the deductible has been met, coverage is
provided for the Medicare Part B coinsurance amount up to
Medicare’s approved charge and for the cost of the first three pints
of blood per calendar year. Additional coverage is furnished for
residential and nonresidential treatment programs, cancer
screening and temporomandibular joint syndrome (TMJ). It also
covers 80 percent of emergency care received in a foreign country.
The plan also offers four separate additional coverage options,
which include: Preventative care coverage, coverage of Medicare
Part A inpatient hospital deductible, coverage of Medicare Part B
annual deductible, and coverage of 100 percent of eligible medical
expenses and supplies not covered by Medicare Part B that exceed
Medicare approved charges. These options can be purchased to
supplement coverage available through the base plan according to
the needs of the member.
Under this plan, Medicare is the primary payer. Claims must be
submitted to Blue Cross with a copy of the Medicare Remittance
Advice (RA) form.
Extended Basic Blue ® The Extended Basic Medicare supplement plan is the most
comprehensive plan that Blue Cross offers. Coverage is furnished
Medicare coinsurance, deductibles, preventive care up to $120 of
eligible charges annually, 20 extra days in a skilled nursing facility
and extra home health care expenses. Member out of pocket is
limited to $1,000 of eligible charges each year.
Members who were enrolled in this plan with optional drug prior
to January 1, 2006 are able to retain their 80 percent prescription
drug coverage. That prescription coverage plan is creditable
according to CMS guidelines.
Under this plan, Medicare is the primary payer. Claims must be
submitted to Blue Cross with a copy of the Medicare RA form.
5-10 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10)

Health Care Options
Senior Gold SM Senior Gold, also referred to as the Medicare Select plan, offers
seniors comprehensive coverage within the Blue Cross
participating provider network and the freedom of choice
associated with fee-for-service plans. Senior Gold has been, and
continues to be, our most popular Medicare supplemental product.
Members receive the highest level of benefits for services in the
participating provider network and also have excellent coverage
when traveling. There are no copays or deductibles for services
received from Blue Cross participating providers. Senior Gold also
offers optional preventive screenings and services not covered by
Medicare. Senior Gold members enrolled in the optional
prescription drug coverage prior to January 1, 2006 may retain that
coverage, however; that coverage is not creditable according to
Medicare guidelines. The optional prescription drug coverage is
not available to new Senior Gold enrollees (those enrolling after
December 31, 2005).
On claims where assignment is taken, Blue Cross pays Medicare
coinsurance and deductible only. Under this plan, Medicare is the
primary payer. Claims must be submitted to Blue Cross with a
copy of the Medicare RA form.
This product is also available for fully insured employer groups to
purchase for their Medicare eligible members. The logo on the
member ID card for any such group members will be prefaced
with “Group”. Benefits may vary by group.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10) 5-11

Health Care Options
Platinum Blue SM (Cost) Blue Cross has made a commitment to offer a broader variety of
Medicare products to eligible Minnesota Medicare beneficiaries. In
mid-2005, Blue Cross introduced its Medicare Cost product,
VantageBlue, statewide. Effective January 1, 2010, VantageBlue
was renamed Platinum Blue and offered three plan options.
Platinum Blue is an open access product for Medicare
beneficiaries who are residents of Minnesota, offered through a
contract with the Centers for Medicare and Medicaid Services
(CMS).
Members can chose from three different medical benefits plan
options:
• Core
• Choice
• Complete
Platinum Blue is also offered to employer groups. There are three
options for employer groups: Plan A, Plan B, and Plan C. All
individual and employer group options provide coverage for
Medicare eligible services with expanded coverage levels and
additional benefits. Members who have only Medicare Part B
coverage will not receive any plan coverage for Medicare Part A
services.
The Core option requires copays for inpatient hospital, inpatient
mental health care, urgently needed care and emergency room
visits, but requires 20 percent coinsurance for many other services
covered.
The Choice option also requires $50 to $100 copays for inpatient
hospital care, inpatient mental health care, urgently needed care
and emergency room visits, as well as $10 copays for many other
services. Some benefits require coinsurance.
The Complete option offers the most comprehensive coverage,
having all the benefits of the Core and Choice options but
generally at $0 copay. A few benefits require 20 percent
coinsurance.
All individual and group plan options include travel coverage (innetwork
benefit levels when traveling in the United States, but
outside of Minnesota), health and wellness education, and a fitness
program. The Choice and Complete individual and Plan A, Plan B
and Plan C group plan options also include benefits for hearing
aids and fittings and vision exams and eyewear.
5-12 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10)

Platinum Blue SM (Cost)
(continued)
MedicareBlue PPO
(Regional PPO)
Health Care Options
The Plan C employer group option requires copays for most
services, including inpatient hospital, mental health services and
emergency room visits. The Plan B option requires similar copays,
but does not require a copay for inpatient hospital care and
inpatient mental health.
No referrals are needed for in-network doctors, specialists or
hospitals. It is important to note that both individual and group
Platinum Blue members can receive plan benefits for services
received outside of Minnesota when traveling for up to nine
months per year. This differs from out of network coverage while
in Minnesota. If, while in Minnesota, members go to a provider
outside of the Platinum Blue (Cost) network who accepts Medicare
patients, members are covered under Original Medicare and would
pay the Part A and Part B deductibles and coinsurance.
Claims administration for Platinum Blue is shared by Blue Cross
and Medicare. Medicare is the primary claim processing entity for
most Medicare Part A eligible services, with some exceptions.
Claims for services eligible under Medicare Part B will generally
be administered by Blue Cross, again, with some exceptions.
This product is also available for fully insured employer groups to
purchase for their Medicare eligible members. The logo on the
member ID card for any such group members will be prefaced
with “Group”. Benefits may vary by group.
A more recent introduction in the Blue Cross Medicare product
expansion is MedicareBlue PPO. This is a regional Medicare
Advantage product offered through the coordination of six Blue
Cross plans covering seven states.
The service area for this plan encompasses Iowa, Minnesota,
Montana, Nebraska, North Dakota, South Dakota and Wyoming.
The plan was introduced across the region with a first effective
date of January 1, 2006.
This product offers one medical benefit level option with Medicare
Part D (prescription drug) coverage included. The plan covers the
full range of basic Medicare covered services, with expanded
coverage levels and additional benefits. Additional benefits
include: hearing services, vision services, physical exams,
health/wellness education (newsletter, nurse hotline, and disease
management).
MedicareBlue PPO members are free to receive care either in or
out of network, however; while in-network care is generally
subject to a copay, out-of-network care is generally subject to
coinsurance.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10) 5-13

Health Care Options
MedicareBlue PPO
(Regional PPO)
(continued)
PLEASE NOTE: The Blue Cross provider manual is not
applicable to this product, nor is the Blue Cross provider
services number. Provider information for MedicareBlue PPO
can be found at:
http://www.yourmedicaresolutions.com/for_providers/
This product is also available for fully insured employer groups to
purchase for their Medicare eligible members. Benefits may vary
by group.
MedicareBlue Rx (PDP) Another recent introduction in the Blue Cross Medicare product
portfolio is MedicareBlue Rx. This is a regional Medicare Part D
Program product offered through the coordination of six Blue
Cross plans covering seven states. The service area for this plan
encompasses Iowa, Minnesota, Montana, Nebraska, North Dakota,
South Dakota and Wyoming. The plan was introduced across the
region with a first effective date of January 1, 2006.
This product, as of January 1, 2011, offers two different benefit
level options: Standard and Premier. The design of Standard
includes a $310 annual deductible, 25 percent coinsurance and a 4
tier formulary. Premier has no annual deductible and has copays or
coinsurance depending on the drug’s formulary placement, which
is 4 tiers, and has some benefits in the coverage gap. Both plan
options include catastrophic coverage after $4,550 annual out of
pocket and formulary exceptions processes. Drugs in the
formularies may be subject to step therapy, quantity limits, or prior
authorization.
PLEASE NOTE: Forms, formularies and provider
information for MedicareBlue Rx can be found at:
http://www.yourmedicaresolutions.com/for_providers/
This product is also available for fully insured employer groups to
purchase for their Medicare eligible members. The logo on the
member ID card for any such group members will be prefaced
with “Group”. Benefits may vary by group.
5-14 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10)

Guidelines for
Determining
Submissions to
Medicare or Blue Cross
Inquiries and Claims
Platinum Blue (Cost)
Health Care Options
For services provided to Medicare members enrolled in our
Medicare supplement or Platinum Blue plan that are eligible under
Medicare Part A, Medicare is primary. CMS will continue to be
the primary payor for these services with electronic claims
crossing over from Medicare intermediaries. Blue Cross will serve
as secondary payor for these services with members being subject
to Medicare coinsurance and deductibles.
Blue Cross is the administrator for Medicare Part B nonfacilitybased
services and any additional Platinum Blue benefits.
Reimbursement for professional providers utilize Blue Cross’
contracted fee schedule methodology. Current reimbursement uses
2005 RVUs with Medicare conversion factors and is GPCI
adjusted (geographical adjustment). For the initial product launch,
Medicare part B services will apply CCI edits at the claim level; as
Blue Cross’ functionality evolves; auto adjudication will occur. To
ensure CMS compliance, follow the guidelines outlined in
standard Medicare bulletins and the Provider Policy and Procedure
manual.
For Medicare members enrolled in our Medicare Advantage plans,
including MedicareBlue PPO, Blue Cross replaces Medicare as
primary payor. Please see the information available on medical
policy, claims submission and payment, etc at:
http://www.yourmedicaresolutions.com/for_providers/
Provider claim and benefit inquiries for Platinum Blue can be
directed to provider web self-service, BLUELINE or provider
services at (651) 662-6500 or 1-800-262-0820.
Care management inquires should be directed to (651) 662-5520 or
1-800-528-0934.
Services eligible under Medicare part B and that would otherwise
be billed to the Medicare carrier on a professional claims
form/format, should be submitted directly to Blue Cross
electronically, whenever possible.
Group number for Platinum Blue individual members are:
• Y0704 - C0 - Platinum Blue Core Option
• Y0704 - C4 - Platinum Blue Core Option-Medicare B only
members
• Y0704 - H1 - Platinum Blue Core Option - Medicare Hospice
enrolled members
• Y0705 - C0 - Platinum Blue Choice Option
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10) 5-15

Health Care Options
Inquiries and Claims
Platinum Blue (Cost)
(continued)
• Y0705 - C4 - Platinum Blue Choice Option-Medicare B only
members
• Y0705 - H1 - Platinum Blue Choice Option - Medicare hospice
enrolled members
• Y0706 - C0 - Platinum Blue Complete Option
• Y0706 - C4 - Platinum Blue Complete Option-Medicare B
only members
• Y0706 - H0 - Platinum Blue Complete Option - Medicare
hospice enrolled members
Please see the grid that follows for an overview of services, CMS
billing format, and Medicare Part A or Part B eligibility.
5-16 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10)

Health Care Options
The following grid provides an overview of Platinum Blue services, CMS billing format, and Medicare Part A or Part B eligibility.
Institutional = electronic format or paper (UB) form professional = electronic format or paper (1500) form
Billable to Medicare
Inpatient and outpatient hospital including Acute
Care Hospital, Indian Health Service Facility
(IHS), Critical Access Hospital, Sole Community
Hospital, Rehabilitation Hospital, etc.
Medicare
submission
form/format Billable to Blue Cross
institutional
Physician services rendered in the inpatient
hospital setting and separately billed
Hospital-based surgical center institutional Free-standing ambulatory surgical center (ASC)
Inpatient and outpatient blood transfusions
Outpatient hospital radiology and laboratory
services
Hospital based therapy including physical,
occupational, and speech
Individual private practice physical therapy office
meeting CMS variance qualifications
institutional
and/or
professional
institutional
institutional
Skilled Nursing Facility (SNF) institutional
Hospice except for services not related to
treatment of terminal condition
ESRD facility (CMS approved dialysis facility) Bills
for support services and back up dialysis and
emergency services only. (global fee
includes some physician services)
Blue Cross
submission
form/format
professional
institutional
(deviates
from CMS)
Physician office visits professional
Professional behavioral health services including
Community Mental Health Centers
Freestanding clinic/physician group physical,
occupational or speech therapy
professional
professional
professional Chiropractic services professional
institutional
institutional
and/or
professional
Home health agencies institutional
Federally Qualified Health Centers (FQHC) [both
Independent and Provider based]
Rural Health Clinic (RHC)
[both Independent and Provider Based]
institutional
institutional
SNF provision of certain prosthetics (PEN
therapy) billed to DMERC
Hospice services unrelated to treatment of
terminal condition and Medicare eligible
Laboratory and X-rays including hospital
reference labs
Home health agencies (also approved as DME
suppliers) billing for DMEPOS services
Durable Medical Equipment (DME), prosthetics,
orthotics, and medical supplies
professional
professional
professional
professional
professional
Hospital-based ambulance institutional Ambulance professional
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10) 5-17

Health Care Options
Additional information available from CMS at:
http://www.cms.hhs.gov/healthplans/rates/out-of-network/default.asp#_Toc77576994
Sample Member ID card
Front of member ID card Back of member ID card
Name
ELIZABETH SAMPLENAME
ID Member #
XZVXZ0000000 00
Svc Types
Office Copay 20.00
ER Copay 60.00
RxNetwork SELECT
GRP
Care
Type
RxBIN
RxPCN
Platinum
Blue
(Cost) H2461
Y0704-C0
MEDICARE COST
CNTRCT
610455
PGIGN
Members: See your Evidence of Coverage for
covered services or other important
information. Possession of this card does not
guarantee eligibility of benefits.
Providers: If you are a Platinum Blue (Cost)
provider, submit Medicare part A claims to
Medicare, and Medicare part B claims to
BCBSM. For all providers, submit both
Medicare part A & B to Medicare.
Blue Cross and Blue Shield of Minnesota is an
independent licensee of the Blue Cross and
Blue Shield Association
www.bluecrossmn.com
Customer Service or Complaints
(651) 662-5654
1-866-340-8654
Provider Service: 1-800-
262-0820
24-Hour Nurse Advice: 1-800-
622-9524
Medical TTY: 1-888-
878-0137
Find a Pharmacy: 1-800-
509-0545
Pharmacist Only: 1-800-
821-4795
Blue Cross and Blue Shield
of Minnesota
P.O. Box 64338
St. Paul, MN 55164-0338
5-18 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10)

Blue Plus Coverage Options
Health Care Options
Comprehensive Plan This Blue Plus plan places a major emphasis on staying well,
maintaining fitness, and preventing potential health problems by
providing full coverage for basic care, such as annual physical
examinations, PAP tests, immunizations, and vaccinations, when
members use their predesignated clinic. Basic to this
comprehensive plan is coverage for lab work, X-rays, hospital care
and specialists’ consultations when provided or authorized by the
predesignated clinic. The plan also covers emergency treatment
anywhere in the world.
Preferred Gold SM Preferred Gold, a ‘‘triple option’’ plan, offers its members three
levels of benefits, depending on which provider network they elect
to use. Preferred Gold members select a primary care clinic and
receive the highest level of coverage for medical care provided or
authorized by that clinic. Access to ob/gyn care and other open
access benefits is available without a referral. Office visit copays
may apply. Specialist care, when referred by the primary care
clinic, is also covered.
Preferred Gold also offers its members the opportunity to self refer
to any provider or hospital and still receive coverage at a reduced
level. Under this second benefit level, Preferred Gold members
may use providers from Blue Cross’ extended network and receive
80 percent coverage after an annual deductible for most services.
Under the third level, out-of-network providers may be used, but
benefits are reduced or unavailable.
Triple Gold Triple Gold is a ‘‘triple option’’ plan for self-insured groups. It is
structured very much like Preferred Gold, but benefits may vary.
Medicare Select
Product
Medicare is primary for all services. For the highest level of
benefits, all care must be provided or referred by the member’s
primary care clinic. There are no benefits under the Medicare
Select contract for services outside the network, although coverage
through Medicare for eligible services is still available to the
member. Medical emergencies, however, are covered whether a
member is at home or traveling. The applicable Medicare
deductible and coinsurance amounts are the member’s
responsibility. Enrollment in Medicare Select is closed.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10) 5-19

Health Care Options
Minnesota Senior
Health Options (MSHO)
/ Secure Blue (HMO)
Blue Plus offers a Minnesota Senior Health Options (MSHO)
product called SecureBlue for dual eligible seniors. SecureBlue is
a Special Needs Plan (SNP) offered under Medicare Advantage by
Blue Plus. Blue Plus has a contract with both the Centers for
Medicare and Medicaid Services (CMS) and the Minnesota
Department of Human Services (DHS) for SecureBlue that creates
an alternative delivery system for acute and long-term care
services and integrates Medicare and Medicaid funding.
SecureBlue combines the services and benefits of Medicare Parts
A and B, including Part D prescription drug coverage, and
Medicaid benefits.
A personal care coordinator will work closely with individual
SecureBlue members to assist them in achieving optimal medical
and social stability.
For SecureBlue members, Blue Plus is billed as primary not
Medicare. SecureBlue members can be identified by ID numbers
beginning with an “XZS8” + the member’s PMI# and group
numbers that begin with “PP2”. Enrollment eligibility may change
monthly. Providers must verify eligibility through any electronic
data system currently being used to access Medical Assistance
eligibility such as Medifax, BLUELINE, the Department of
Human Services Eligibility Verification System (EVS), provider
web self-service, or Blue Cross provider services.
SecureBlue includes 180 days of nursing home coverage and
Elderly Waiver services. The only copays for SecureBlue members
are for prescriptions. Members must designate a primary care
clinic, however, referrals are not required for services at
participating providers. Services are coordinated through a
personal care coordinator. All Blue Plus referral providers are
included in the specialty network. Providers should file their
claims with Blue Cross.
5-20 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10)

Prepaid Medical
Assistance Program
(PMAP), and Minnesota
Senior Care Plus
(MSC+) / Blue
Advantage
Health Care Options
The Blue Advantage Prepaid Medical Assistance Program
(PMAP) and Minnesota Senior Care Plus (MSC+) are Minnesota
health care programs funded jointly by the state and federal
governments. Blue Plus has a contract with Minnesota Department
of Human Services (DHS) to provide services for specific county
Medicaid enrollees (MSC+ is for seniors 65+).
Blue Plus Blue Advantage members can be identified by ID
numbers beginning with “XZG8” and group numbers that start
with “PP0”. Enrollment eligibility may change monthly. Providers
must verify eligibility through any electronic data system currently
being used to access Medical Assistance eligibility such as
Medifax, BLUELINE, the Department of Human Services MN-
ITS, provider web self-service, or Blue Cross provider services.
Members designate a primary care clinic to provide or coordinate
their care. No referrals are required for access to services from
providers who participate in the Blue Plus or Aware networks,
except for chiropractic services. Members must obtain
chiropractic services from providers in the Select Chiropractic
network. There are some providers in the Public Programs referral
network that are not listed in the provider directory (i.e., nonambulatory
transportation, hearing aids, and public health). For
behavioral health, members have direct access to in-network
providers. In rare instances, out-of-network exceptions may be
considered. Call the number on the back of the member’s ID card,
or call 1-800-262-0820 (local 651-662-5200). Providers should
file their claims with Blue Cross. Please refer to Chapter 3 of the
Blus Plus Manual for more detailed information on Government
Programs.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10) 5-21

Health Care Options
MinnesotaCare
Program
MinnesotaCare is a state-subsidized health program. It is funded
by member premiums, the state of Minnesota, a tax on health care
providers and some federal matching dollars. It is open to all
Minnesotans who meet program and income guidelines and do not
have access to health insurance.
MinnesotaCare members can be identified by ID numbers
beginning with an “XZG8” and group numbers that begin with
“PP1”. Enrollment eligibility may change monthly. Providers must
verify eligibility through any electronic data system being used to
access Medical Assistance eligibility such as Medifax,
BLUELINE, the Department of Human Services MN-ITS,
provider web self-service, or Blue Cross provider services.
Member ID cards look similar to cards for PMAP.
Benefits for children under 21 and pregnant women are the same
as the PMAP benefits except for common carrier transportation.
Adults have a reduced benefit set and have some copays. Members
must designate a primary care clinic and referrals are not required
if within the participating provider network. All Blue Plus Referral
providers are included in the specialty network. Providers should
file their claims with Blue Cross.
See Chapter 3 of the Blue Plus Provider Manual for more complete
information.
5-22 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10)

Federal Employee Program
Federal Employee
Program (FEP)
Health Care Options
The Federal Employee Program (FEP), one of the health benefit
plans available to federal government employees and their
dependents, is administered by Blue Cross and Blue Shield plans
throughout the country. Enrollment, eligibility, and claims records
for all FEP members are maintained in Washington, D.C. We have
access to the records through a national telecommunications
system.
The unique federal ID number, which always begins with an “R”
and is followed by eight digits, identifies FEP members.
Federal employees may choose Basic Option or Standard Option
Blue Cross and Blue Shield coverage. Providers should file all
claims for FEP benefits within the local plan, (i.e., Minnesota
providers submit to Blue Cross and North Dakota providers submit
to Blue Cross and Blue Shield of North Dakota). All claims must
be submitted no later than December 31 of the calendar year after
the one in which the covered care or service was provided, unless
timely filing was prevented by administrative operations of
government or legal incapacity, provided the claim was submitted
as soon as reasonably possible. Once benefits have been paid, there
is a three-year limitation on the reissuance of uncashed checks.
Providers can call a new automated voice response unit (VRU) to
check eligibility and benefits for FEP members. To access this
service, call (651) 662-5044 or 1-800-859-2128. Claim status is
currently not available through the VRU.
Provider Statements Your Statement of Provider Claims Paid and Statement of
Institutional Claims Paid for FEP members will be posted on a
separate remit. You will also receive a separate check titled
“Federal Employee Program” with the Blue Cross logo for your
FEP members. Recoupments and credit claim activities for FEP
members will be reflected on a separate Accounts Receivable
Recoupment Report which will be titled “Federal Employee
Program.”
Benefit Changes Visit www.fepblue.org for current benefit information.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10) 5-23

Health Care Options
BlueLinkTPA
BlueLink TPA
BlueLink is an affiliate of Blue Cross and an independent licensee
of the Blue Cross and Blue Shield Association serving residents
and businesses of Minnesota. BlueLink utilizes the Blue Cross
network of participating providers, provider contract pricing, Blue
Distinctions Centers of excellence and the Care Comparison online
tool.. Plan benefits vary by employer, all which are self-insured.
Some BlueLink employer customers use remote processing,
meaning that claims come to Blue Cross, they are priced, and then
sent to the employer to complete the claims processing. There are
also employers who utilize our Blue Cross networks but process
their claims through a third-party administrator.
Providers have access to benefits information for BlueLink
members through PWSS.
The BlueCard program enables a BlueLink member obtaining
health care services while traveling or living in another plan’s
service area to receive the benefits of the Blue Cross plan listed on
their member ID card and to access the local plan’s provider
networks and savings.
For inquiries, adjustments or appeals contact the employer or the
third-party administrator directly. File electronic claims to Blue
Cross. Mail scannable paper claims to:
BlueLink TPA
P.O. Box 64668
St. Paul, MN 55164
5-24 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10)

Healthy Start ® Prenatal Support
Healthy Start ® Prenatal
Support
Healthy Start ®
Prenatal Support
(continued)
Health Care Options
Healthy Start is a personalized program designed to assess, educate
and support pregnant women and their health care providers to
achieve optimal childbirth outcomes. Registered nurses who are
experienced in obstetrics work with the expectant mother to help
her achieve a normal full-term delivery. With a quick phone call, a
Healthy Start nurse is there to give answers and support.
Healthy Start offers these features:
• An experienced obstetrics registered nurse who educates the
mother-to-be on having a healthy pregnancy and answers her
questions.
• Comprehensive educational material that is tailored to the
specific needs of the mother-to-be.
• Guidance on nutrition, exercise, birth planning, stress
management, relieving discomfort, explanation of procedures
and much more.
• A reward card to the participant’s choice of major retail stores.
There is no cost for participation in the Healthy Start program.
Healthy Start is available to all Blue Cross fully insured members,
Blue Plus members and members of self-insured groups that have
purchased this program. It is not available to members with
individual policies.
To enroll, please instruct members who are expecting a baby to the
back of their member ID card for the appropriate contact number.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10) 5-25

Health Care Options
Delta Dental
History Delta Dental of Minnesota offers dental coverage to individuals
and small and large groups in Minnesota. Delta Dental operates
pursuant to an administrative service agreement with Blue Cross.
Delta Dental of Minnesota is independent from Blue Cross. Delta
Dental provides administrative services for dental benefits.
Inquiries Delta Dental inquiries may be directed to:
Delta Dental
3560 Delta Dental Drive
Eagan, MN 55112
Phone: (651) 406-5900 or 1-800-328-1188
Fax: (651) 994-5035
Website: www.deltadentalmn.org
5-26 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10)

MII Life, Incorporated
Health Care Options
History MII Life, Incorporated administers reimbursement account
products (flexible spending accounts, health reimbursement
arrangements, health savings accounts) under the name
SelectAccount ® .
MII Life, Inc., d.b.a. SelectAccount, is an independent company
providing account administration services.
Products and Services SelectAccount’s product line includes:
• Flexible spending accounts (FSAs)
• Medical savings accounts (MSAs)
• Health reimbursement arrangements (HRAs)
• Health savings accounts (HSAs)
• VEBA accounts
• Transportation reimbursement accounts
These products are offered as stand-alone products or in
conjunction with Blue Cross plans.
• SelectAccount customer service ............1-800-859-2144
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10) 5-27

Health Care Options
Prime Therapeutics LLC
History Prime Therapeutics, LLC is Blue Cross’ pharmacy benefits
manager (PBM).
Prime Therapeutics, LLC is an independent company providing
pharmacy benefit management services.
Formularies Blue Cross offers two formulary options to meet customer and
member needs.
GenRx is the formulary option designed for maximum value in
pharmacy spending for clients and members while maintaining the
highest standards in therapeutic safety and effectiveness. Its focus
is to provide the same high therapeutic standard as FlexRx by
having both brand-name and specialty drugs on this formulary
while placing greater emphasis on lower-cost generic equivalents.
GenRx addresses a rapidly growing need in a marketplace looking
for high-quality, cost-conscious benefit solutions.
FlexRx is the broadest formulary option providing the highest
standard of therapeutic safety and effectiveness through a
combination of brand-name and generic drugs, including specialty
drugs.
5-28 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10)

Workers’ Compensation, No-Fault Auto &
Subrogation
Health Care Options
Overview Following is a Question and Answer guide to assist you in
reimbursement of Workers Compensation, No-Fault Auto and
Subrogation claims.
Workers'
Compensation, No-
Fault Auto &
Subrogation
1. What does Blue Cross need if the workers’ compensation
carrier, or the automobile carrier/third party liability
carrier denies?
We need a letter from the other carrier, stating the specific date
of service on the claim they are wanting paid and the reason
the other carrier is not paying claims.
2. Why do claims deny when they are not marked
work/auto/subro related?
Once we have identified a workers’ compensation or
automobile or subrogation claim, an indicator is placed on the
patient’s file. All claims that are possibly related to the
indicated injury are denied.
3. Why do claims continue to deny when a denial has been
sent in?
The denial must be valid in order for Blue Cross to pay the
claims under the health benefits. The denial is not valid unless
it specifies why the other insurance carrier is denying and they
provide a specific reason behind the denial such as doctor’s
opinion, IME, etc. If the denial is date specific, only the dates
listed on the denial are adjusted.
4. Why does Blue Cross need a denial from the workers’
compensation carrier if the doctor states it is not work
related?
A notification from the workers’ compensation carrier is
needed if the treatment is similar to the work injury. The
workers’ compensation carrier must make the final
determination.
5. Why do some claims pay and some deny?
If the diagnosis is non-specific (like pain in a limb) and we are
unable to determine what is being treated the claim may deny.
If we have limited information on what the injury is, some
claims may pay while others may deny.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10) 5-29

Health Care Options
Workers'
Compensation, No-
Fault Auto &
Subrogation
(continued)
6. When does Blue Cross need chart notes to adjust claims?
The chart notes should indicate what the patient was treated
for. If the chart notes indicate the treatment was not related to
the work injury, the motor vehicle accident or the third party
accident, then claims can be adjusted. If chart notes are nonspecific
or treatment is similar to the accepted injury, a valid
denial is needed from the other insurance carrier.
7. If there is an intervention case does Blue Cross pay claims?
Depending on the circumstances surrounding the litigation,
Blue Cross may or may not pay claims. If you have case
specific questions you should contact the Special Services Unit
directly at 1-866-251-6691.
8. If the member has a pre-paid medical or MNCare group
can we bill them?
No. As a provider you need to bill the other insurance carrier.
If you do not know who the other insurance carrier is, then you
must try to contact the member three times for this
information. If you are unable to get a response from the
member, then Blue Cross will adjust claims to pay, under the
health benefit, once the documentation is received showing the
three attempts to contact the member.
9. What are the no-fault laws for Minnesota and surrounding
states?
Minnesota and North Dakota have mandatory medical pay
laws. This means all drivers insured in Minnesota or North
Dakota have medical pay on their auto insurance. Minnesota
has a $20,000 medical pay limit. North Dakota has a
$30,000.00 medical pay limit. South Dakota, Iowa and
Wisconsin are optional states which mean the member can
chose to either have or not to have medical pay on their auto
policy.
10. What are some uncommon injuries that may be covered by
the workers’ compensation carrier?
The workers’ compensation carrier may cover injuries that
occur when an employee trips or falls at work, is injured in the
parking lot, is hurt volunteering or is hurt when traveling for
work. If you have specific questions regarding a potential work
related injury contact the Special Services Unit.
5-30 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10)

Workers'
Compensation, No-
Fault Auto &
Subrogation
(continued)
HICF 1500 Form Locator 837P
Health Care Options
11. What are some uncommon injuries that maybe covered by
the automobile or third party insurance?
The automobile or third party insurance may cover injuries that
occur while the individual is at someone else’s home, on
someone else’s private property, at a place of business, due to a
dog bite, or when they are a pedestrian or bicyclist injured by a
motor vehicle.
12. Does health insurance coordinate with auto/third party or
workers’ compensation insurance?
No. In most circumstance the other insurance is primary. Once
the other insurance carrier has exhausted their payments,
claims may be payable under the health insurance policy.
13. Who should claims be filed to if the patient is working and
has an auto accident?
The claims should first be filed to the workers’ compensation
carrier. If they deny stating the employee was not in the scope
of their employment, then the claim should be filed to the auto
insurance carrier. If the auto insurance carrier denies or
benefits are exhausted, the claim should be billed to Blue Cross
with a copy of both the workers’ compensation denial and the
auto carriers exhaust letter, EOB, or payment log.
14. What should be done if a claim was paid by both Blue
Cross and another insurance company?
Option 1: Request a void/replacement claim. Refer to Chapter
10 for information regarding submission of void/replacement
claims. Note that effective July 15, 2009, only out of state,
nonparticipating providers are allowed to submit paper claim
forms per Minnesota Statute 62J.536 and the Blue Cross
provider contracts.
Information indicating if the patient’s condition is related to
employment, auto or other accident, or workers‘ compensation
should be indicated on the replacement claim.
For professional claims (HICF-1500 or 837P) complete the
items indicated below.
Item # Title Loop ID Segment Notes
10a Is Patient’s
Condition
Related to:
Employment
2300 CLM11 Titled Related Causes Code in
the 837P
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10) 5-31

Health Care Options
HICF 1500 Form Locator 837P
Item # Title Loop ID Segment Notes
10b Is Patient’s
Condition
Related to: Auto
Accident
10c Is Patient’s
Condition
Related to: Other
Accident
10d Reserved for
local use
14 Date of Current
Illness, Injury,
Pregnancy
2300 CLM11 Titled Related Causes Code in
the 837P
2300 CLM11 Titled Related Causes Code in
the 837P
2300 K3 This is specific for reporting
Workers’ Compensation
Condition Codes.
2300 DTP03 Titled in the 837P:
a. Onset of current illness or
injury date.
b. Acute manifestation date.
c. Accident date.
d. Last menstrual period
date.
For institutional claims (UB-04 or 837I) report the appropriate
occurrence code. Occurrence codes and dates are entered in
Form Locator(s) 31-34, 35-36 on the UB-04 or in Loop 2300
of the 4010A1 837I transaction. The following occurrence
codes may be submitted as appropriate.
01:Accident / Medical Coverage
Code indicating accident-related injury for which there is
medical payment coverage. Provide the date of accident /
injury.
02: No Fault Insurance Involved - Including Auto
Accident/ Other
Code indicating the date of an accident, including auto or other
where state has applicable no-fault liability laws (i.e., legal
basis for settlement without admission or proof of guilt).
5-32 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10)

Workers'
Compensation, No-
Fault Auto &
Subrogation
(continued)
03: Accident/Tort Liability
Health Care Options
Code indicating the date of an accident resulting from a third
party’s action that may involve a civil court process in an
attempt to require payment by the third party, other than nofault
liability.
04: Accident/ Employment-Related
Code indicating the date of an accident allegedly relating to the
patient’s employment.
OPTION 2: Contact the Special Services Unit at
1-866-251-6691 and request the claim is adjusted.
15. Should claims that are related to a work/auto/third party
injury be billed to Blue Cross?
Claims that are related to a work/auto/third party injury should
be billed to the liable insurance carrier and not to Blue Cross.
If the other insurance carrier denies, then the claim should be
billed to Blue Cross with a copy of the other insurance carrier’s
denial and/or EOB attached.
On occasion the other insurance carrier may not process the
claim in a timely manner and due to Blue Cross timely filing
guidelines, you may need to bill to Blue Cross prior to getting
an EOB or denial from the other carrier. If this occurs, you
should submit the claim to Blue Cross and note in the HICF
1500, form locator 10 or the 837P for professional claims (as
noted under 14. above) or the appropriate occurrence code for
institutional claims. Occurrence codes and dates are entered in
Form Locator(s) 31-34, 35-36 on the UB-04 or in Loop 2300
of the 4010A1 837I transaction.
16. How can I reach the Special Services Unit if I have other
questions or concerns related to a work/auto/third party
injury?
The Special Services Unit can be reached by direct dial at
1-866-251-6691. Monday through Thursday 8:00 am -
4:30 pm, Friday 9:00 am - 4:30 pm, CT
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10) 5-33

Health Care Options
Networks
Blue Cross (Aware) An extensive open access network which includes nearly every
physician and hospital in Minnesota. This network is used with
major medical plans and open access/preferred provider-type
products.
Select Networks Available for substance abuse, behavioral health and chiropractic
care services. They are standard for small and large insured groups
and offer a savings advantage.
Blue Plus ® Our most exclusive primary network that includes more than 7,500
physicians. Members enrolled in managed care products choose a
primary care clinic from the Blue Plus network to coordinate their
care and make referrals to network specialists.
BlueCard ® A national network managed by the Blue Cross and Blue Shield
Association. Local Blue plans can sell national account business
by leveraging the 50-state Blues provider network.
Blue Distinction
Centers ®
A national centers of excellence program that enables members to
make more informed health care decisions to improve outcomes.
Facilities must meet strict clinical criteria to earn the Blue
Distinction Centers designation for transplants, transplants and
cardiac care.
Note: Designation as Blue Distinction Centers means these
facilities’ overall experience and aggregate data met
objective criteria established in collaboration with expert
clinicians’ and leading professional organizations’
recommendations. Individual outcomes may vary. To find
out which services are covered, please call Blue Cross.
Blue Precision ® A high performance, tiered network. In it, all providers within the
Blue Cross (Aware) network are tiered into one of two levels, and
members make value-based decisions at the point of care. There
are two Blue Precision networks available in Minnesota, one with
greater access to Level 1 providers (Perform) and one with greater
savings (Achieve).
Accord Network Our standard network that includes 97 percent of Minnesota
doctors and hospitals.
Value Network Value is our Minneapolis/St. Paul metro area PPO network that
offers access to the most affordable physicians and hospitals
available to provide a lower cost health plan.
5-34 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10)

Table of Contents
Chapter 6
Blue Plus
Member Information................................................................................................................. 6-2
Introduction to Blue Plus ® .....................................................................................................6-2
Blue Plus Network Participation............................................................................................ 6-2
Department of Health.............................................................................................................6-2
Member Rights and Responsibilities .....................................................................................6-3
Member Benefits....................................................................................................................6-8
Member PCC Selection..........................................................................................................6-9
Claim Processing ...................................................................................................................6-9
Statement of Provider Claims Paid Form ..............................................................................6-9
Quality of Care Complaint...................................................................................................6-10
Referrals.................................................................................................................................... 6-11
Overview..............................................................................................................................6-11
Referral Policy .....................................................................................................................6-11
Referral Points .....................................................................................................................6-12
Referral Required.................................................................................................................6-13
Referral Not Required.......................................................................................................... 6-14
Standing Referral .................................................................................................................6-16
Clarifications of Terms ........................................................................................................6-17
Referral Letter......................................................................................................................6-18
Sample Patient Referral Authorization Letter ..................................................................... 6-19
Special Member Benefits......................................................................................................... 6-22
Overview..............................................................................................................................6-22
Chiropractic Benefits ...........................................................................................................6-22
Continuity of Care After Facility Discharge........................................................................6-22
Durable Medical Equipment................................................................................................6-22
Mental Health and Chemical Dependency Services............................................................6-23
OB/GYN Services................................................................................................................ 6-23
OB/GYN Open Access Additional Services........................................................................6-23
OB/GYN Open Access Diagnosis .......................................................................................6-24
Vision Care ..........................................................................................................................6-26
Blue Cross Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10) 6-1

Blue Plus
Member Information
Introduction to
Blue Plus ®
Blue Plus Network
Participation
We developed this chapter for all Blue Plus providers and their
business staff. The information contained in this chapter will give
the referral (specialty care) providers access to Blue Plus
information. The Blue Plus Provider Manual for participating
primary care clinics (PCCs) details the information necessary for
the PCC to conduct business with Blue Plus and is intended as a
complement to this manual.
Blue Plus, an affiliate of Blue Cross and Blue Shield of Minnesota,
is a state-certified health maintenance organization (HMO). In
most Blue Plus plans, Members select a participating PCC that
coordinates the patient’s medical care and authorizes treatment by
specialists when necessary.
Because Blue Plus is an affiliate of Blue Cross and Blue Shield of
Minnesota, Blue Plus is subject to most of the same policies and
procedures as Blue Cross and Blue Shield of Minnesota.
To be listed as a participating Blue Plus provider, you need to have
a signed Blue Plus agreement. After participation is established in
the Aware ® network, you can make a written request for a Blue
Plus agreement. Send this request to:
Blue Cross and Blue Shield of Minnesota
Blue Plus Contracting
P.O. Box 64560
St. Paul, MN 55164-0560
Blue Plus will review the request and make a written response.
Note: Blue Plus will not offer Blue Plus agreements to all
requesting health care providers.
Department of Health The Minnesota Department of Health (MDH) regulates HMOs
licensed in Minnesota. It governs the fully insured HMO products,
which includes Blue Plus. The MDH is involved in approving and
monitoring contract changes, provider network access and
changes, appeals, identification cards, quality improvement, and
much more.
6-2 Blue Cross Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10)

Member Rights and
Responsibilities
Blue Plus Member Rights and Responsibilities. Blue Plus
Members receive the following statement of rights:
Your rights as a health plan member:
Blue Plus
• To be treated with respect, dignity and privacy.
• To receive quality health care that is friendly and timely.
• To have available and accessible medically necessary covered
services, including emergency services, 24 hours a day, seven
(7) days a week.
• To be informed of your health problems and to receive
information regarding treatment alternatives and their risk in
order to make an informed choice regardless if the health plan
pays for treatment
• To participate with your health care providers in decisions
about your treatment.
• To give your provider a health care directive or a living will (a
list of instructions about health treatments to be carried out in
the event of incapacity).
• To name the person who can make health care decisions for
you in the event of your incapacity.
• To refuse treatment.
• To have privacy of medical and financial records maintained
by Blue Plus and its health care providers in accordance with
existing law.
• To receive information about Blue Plus, its services, its
providers, and your rights and responsibilities.
• To make recommendations regarding Blue Plus’ rights and
responsibilities policies.
• To have a resource at Blue Plus or at the clinic that you can
contact with any concerns about services.
• To file a complaint with Blue Plus and the Commissioner of
Health and receive a prompt and fair review.
• To initiate a legal proceeding when experiencing a problem
with Blue Plus or its providers.
Blue Cross Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10) 6-3

Blue Plus
Member Rights and
Responsibilities
(continued)
• Medicare enrollees have the right to voluntarily disenroll from
Blue Plus. Blue Plus may not encourage or request you to
disenroll except in circumstances specified in federal law.
• Medicare enrollees have the right to a clear description of
nursing home and home health care benefits covered by Blue
Plus.
You have the responsibility as a health plan member:
• To know your health plan benefits and requirements.
• To provide, to the extent possible, information that Blue Plus
and its providers need in order to care for you.
• To participate in understanding your health problems and
developing mutually agreed-upon treatment goals.
• To follow the treatment plan prescribed by your provider or to
discuss with your provider why you are unable to follow the
treatment plan.
• To provide proof of coverage when you receive services and to
update the clinic with any personal changes, such as name and
address.
• To pay copays at the time of service and to promptly pay
deductibles, coinsurance and, if applicable, charges for services
that are not covered.
• To keep appointments for care or to give early notice if you
need to cancel a scheduled appointment.
6-4 Blue Cross Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10)

Member Rights and
Responsibilities
(continued)
Minnesota Health Care Programs Member Rights and
Responsibilities:
Blue Plus
You have the right to know about your rights and responsibilities.
If you have any questions, please call member services at
(651) 662-5545 or toll free at 1-800-711-9862.
Your rights as a health plan member:
• To get quality health care that’s timely, accessible, and
friendly.
• To be treated with respect, dignity and consideration for
privacy.
• To get medically necessary covered services, including
emergency services 24 hours a day, seven (7) days a week.
• To be told about your health problems.
• To get information about treatment, your treatment choices and
how they may help or harm you – whether or not the health
plan would pay for these treatments.
• To participate with your providers in the decisions about your
health care.
• To participate in understanding your health problems and
developing your treatment goals.
• To refuse treatment. To get information about what might
happen if you refuse treatment.
• To refuse care from specific providers.
• To expect that we will keep your medical and financial records
private.
• To request and receive a copy of your medical records. You
also have the right to ask to correct the records.
• Get notice of our decisions if we deny, reduce, or stop a
service, or deny a payment for a service.
• To file a grievance or appeal with Blue Plus. You can also file
a complaint with the Minnesota Department of Health.
• To request a State Fair Hearing with the Minnesota
Department of Human Services (also referred to as “the
State”). You may request a State Fair Hearing before or at any
time during the Blue Plus appeal process. You do not have to
file an appeal with Blue Plus before you request a State Fair
Hearing.
• To get a clear explanation of covered nursing home and home
care service.
Blue Cross Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10) 6-5

Blue Plus
Member Rights and
Responsibilities
(continued)
• Give written instructions that inform other of your wishes
about your health care. This is called a “health care directive.”
It allows you to name a person (agent) to decide for you if you
are unable to decide, or if you want someone else to decide for
you.
• To choose where you will get family planning services.
• To get a second opinion for medical, mental health and
chemical dependency services.
• To be free of constraints or seclusion used as a means of
coercion, discipline, convenience or retaliation.
• To request a copy of the Certificate of Coverage at least once a
year.
• To recommend changes regarding Blue Plus’ rights and
responsibilities policies.
• To freely exercise your rights. The exercise of your rights will
not badly affect the way you are treated.
• Get the following information from us, if you ask for it:
• Whether we use a physician incentive plan that affects the
use of referral services;
• The type(s) of incentive arrangement used;
• Whether stop-loss protection is provided; and
• Results of member survey if one is required because of our
physician incentive plan.
• Get the results of an external quality review study from the
State, if you ask for them.
• To be told when a health care provider cancels their contract
with Blue Plus. You may choose from the rest of the Blue Plus
providers.
• To have a person at Blue Plus or at the clinic to contact with
any concerns about services.
• To get information about Blue Plus, our services, network of
providers and your rights and responsibilities.
6-6 Blue Cross Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10)

Member Rights and
Responsibilities
(continued)
Blue Plus
• To start a legal proceeding when having a problem with Blue
Plus or our providers.
• To file a grievance or appeal with Blue Plus and receive a
prompt and fair review.
• To contact the State ombudsman for help in filing a grievance
or appeal.
• To ask for a speedy hearing.
Your responsibilities as a health plan member:
• Read your Certificate of Coverage and know which services
are covered under the Plan and how to get them.
• To show your Blue Plus member ID card and your Minnesota
Health Care Programs card every time you go for health care.
Also show the cards of any other health coverage you have,
such as Medicare or private insurance.
• To establish a relationship with a Blue Plus primary care
doctor before you become ill. This helps you and your primary
care doctor understand your total health condition.
• To give information that Blue Plus and our providers need to
give care to you. Share information about your health history.
• To follow all your doctor’s instructions. If you have questions
about your care, you should ask your doctor.
• Work with your doctor to understand your total health
condition. It is important to know what to do when a health
problem occurs, when and where to seek help, and how to
prevent health problems.
• To practice preventive health care. To have tests, exams and
shots recommended for you based on your age and gender.
• To tell the clinic about changes in your name or address.
• To keep appointments for care or to give early notice if you
need to cancel.
This information is available in other forms to people with
disabilities by calling Blue Plus customer service at
(651) 662-5545, toll free at 1-800-711-9862 (voice), or
(651) 662-8700 or 1-888-878-0137 (TDD), or 711, or through
the Minnesota Relay Service at 1-877-627-3848 (speech-tospeech
relay service).
Blue Cross Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10) 6-7

Blue Plus
Member Benefits Members’ benefits depend upon their type of contract. Benefits for
our standard fully insured contracts may vary from our self-insured
contracts. Because members’ benefits will vary, please use
BLUELINE, provider web self-service, or contact provider service
for specific member benefits.
• Highest level of benefits – Members generally receive the
highest level of benefits when they receive their services from
their PCC or when the PCC authorizes a referral to a specialist.
A list of participating referral providers which is online at
www.providerhub.com is available in the Referral Network
for PCCs directory or at bluecrossmn.com.
• Self-referral – Members may decide to manage their own
health care without involving their PCC. We consider this a
self-referral. In doing so, members usually take on additional
financial responsibilities. A claim may be paid at a lesser
benefit or completely denied, depending on if the member has
a self-referral option.
• Referral bypass – There are some services that will be paid at
the highest level of the member’s benefits without a referral
from the PCC. This is known as a referral bypass or referral
exception. For a listing of referral bypasses, please refer to the
Referral Not Required section of this chapter.
• PCC/Care System - Referral bypass- There may be situations
where a particular PCC or care system has communicated their
wish to have a referral bypass implemented for a particular
situation. This allows the specified service to be paid at the
highest level of benefits without you communicating a referral
to us. If you have questions regarding a PCC specific referral
bypass, please contact provider service. These requests are
handled on an individual basis and must be implemented by
Blue Plus and an authorized person at your clinic.
• Open access – Some contracts have open access for specified
services. The member usually uses a designated participating
network provider and will receive the highest level of benefits
without a referral from the PCC. Some examples include
vision, chiropractic, obstetrics/gynecology (ob/gyn), or
behavioral health care.
6-8 Blue Cross Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10)

Blue Plus
Member PCC Selection Members are responsible for selecting their primary care clinic
(PCC). Every member in the family may select their own PCC;
they are not required to select the same PCC. Members may also
change their designated PCC. To do so they must contact Blue
Plus customer service. The phone number is on the back of the
member’s ID card.
The effective date assigned to all PCC changes will be generally
the first day of the month following Blue Plus’s receipt of the
request. This provision may be waived under certain situations.
The effective date of the change will be communicated on the
instructions mailed with the member’s ID card.
Claim Processing When a claim is received for specialty care (not by the PCC), we
will review our records for a referral. If a referral has not been
received or does not match an open referral in our records, we will
process the claim as a self-referral if the member has a self-referral
option. If the member does not have a self-referral option, we may
contact the PCC to inquire if a referral is desired. If no referral is
authorized, then the claim will be denied or processed at the lower
level of benefits.
Statement of Provider
Claims Paid Form
Providers will be notified of claims processing details as outlined
in Chapter 10-Reimbursement/ Reconciliation Programs of this
manual for more details regarding the Blue Plus Statement of
Provider Claims Paid and reimbursement.
Blue Cross Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10) 6-9

Blue Plus
Quality of Care
Complaint
A quality of care complaint is an additional right of Blue Plus
members. Members may complain if they feel the quality of their
care has been reduced. Some examples of quality of care
complaints are listed below. Members may file a complaint if they
believe:
• They are not receiving an appointment in a reasonable amount
of time
• The PCC is not referring them to a specialist when it is
necessary
• The provider/provider office was rude or discourteous
• The provider is unable to diagnosis or treat their condition
We immediately supply the provider with a copy of the complaint
and involve the provider in the solution. We are required by the
Department of Health to complete these complaints in 30 days,
therefore; we require your expedited attention to any request we
may have.
6-10 Blue Cross Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10)

Referrals
Blue Plus
Overview When Blue Plus members are referred by their PCC to other
providers, Blue Plus needs to be notified by the PCC in order for
claims to process correctly. A referral is not a guarantee of
payment, but allows the patient to seek medical care outside
the PCC. A referral does not negate the necessity of a prior
authorization or preadmission notification, if they are required.
Referrals are in addition to both of these procedures for managed
care products.
Once the referral is received from the PCC, Blue Plus will generate
a referral letter depending on the type of referral (see Referral
Letter).
It is the referred provider’s responsibility to communicate medical
assessments and proposed treatment plans to the PCC. To best
coordinate the member’s care, the PCC must have complete
medical information. PCCs may request the information in the
format of their choice.
Referral Policy The referral process occurs when a PCC determines that the
patient’s condition requires care outside his or her PCC. A referral
is initiated by the PCC and is limited to a specific duration and
number of visits, as determined by the PCC. There are some
situations where a referral is not required (see Referrals Not
Required). A prior authorization may be necessary. See the
section on Prior Authorization, Section 6-16. Policies for
Government Programs may have different requirements. See
Chapter 3 in the Blue Plus Provider Manual.
The goal of the referral process is to ensure continuity of care
through coordination with the PCC. When care needs are identified
which cannot be appropriately provided by the PCC, care is
referred.
The objectives of referrals are:
• To promote coordination of care and communication between
patients, PCCs and specialty providers.
• To promote appropriate use of referral care, thereby reducing
under-utilization or over-utilization of services.
• To promote seamless, quality of care delivery by facilitating
the use of a select, coordinated network of primary care and
specialty providers.
Blue Cross Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10) 6-11

Blue Plus
Referral Points Remember these important points about referrals:
• PCCs must have an established referral process.
• PCCs must notify Blue Plus of authorized referrals via our
provider web self-service product at www.providerhub.com.
• The member may receive services only from the clinic named
in the referral or standing referral.
• The referral provider or specialist may not refer members to
other providers without written consent from the PCC. If no
referral is given, members will be responsible for any reduced
benefits. Exceptions are made for Minnesota Health Care
Program Members.
• In some cases, we will request a second referral if information
from the referred provider’s claim does not match information
received on the initial referral.
• If a member who has a referral or standing referral changes
PCCs, the referral or standing referral will no longer be valid
as of the date of the PCC change. The member’s new PCC
must now coordinate their member’s care.
6-12 Blue Cross Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10)

Referral Required If the PCC authorizes the care outside the PCC, referrals are
required to be communicated to Blue Plus for:
Blue Plus
• Home health care/home IV
• Outpatient surgery
• Psychological testing submitted with a medical diagnosis
• Visits to a specialty provider
• Inpatient skilled nursing facilities (SNF) - a referral is required
along with a prior authorization
• Minnesota Health Care Programs and SecureBlue members do
not require a referral for the SNF charges; but, the provider is
required to send in a Nursing Home Communication Form
• Inpatient admissions – including hospitals
• Inpatient hospital admissions – a referral will be assumed when
the preadmission notification is completed, if the admitting
physician is from the member’s PCC
There are times when a referral is appropriate for behavioral health
services. If this is the case, you can call 1-800-262-0820 or local
(651) 662-5200 to discuss referral needs. This phone number can
also be used to see which providers are in the behavioral health
network. Minnesota Health Care Program Members have direct
access to network providers. In rare instances, out-of-network
exceptions may be considered. Call the above numbers for further
information.
There also may be exceptions in situations where the patient has
open-access benefits for a particular type of service.
Blue Cross Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10) 6-13

Blue Plus
Referral Not Required We do not require referrals for the services listed below. Claims
will process at the highest level of coverage, as if they were
referred, without you authorizing a referral. This process is known
as a referral bypass or referral exception. The referral bypasses
may be in place for ease of administration, legislative mandate or
both. They may vary by employer contract or PCC. For complete
information about Minnesota Health Care Programs requirements,
see Chapter 3 in the Blue Plus Provider Manual.
• Abortion and sterilization
• Allergy serum when injection is done in the PCC
• Ambulance transportation
• Anesthesia and assistant surgeon, if medically necessary (if the
outpatient surgery or inpatient admission is referred)
• Covered services by dentists, endodontists, periodontists,
orthodontists, prosthodontists, and oral and maxillofacial
surgeons.
• Diagnostic X-ray and laboratory services only (except MRI)
• Durable medical equipment (DME)
• Emergency services
• Inpatient consultation (if the inpatient admission is referred)
• Inpatient consultation (if the inpatient admission is referred)
• Inpatient delivery/maternity, and related services, including
prenatal and complications of pregnancy
• Inpatient treatment of a medical emergency
• Magnetic Resonance Imaging (MRI)
6-14 Blue Cross Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10)

Referral Not Required
(continued)
Blue Plus
• One postpartum home care visit, if the visit follows an early
discharge. Early discharge for a vaginal delivery would be
within 48 hours of delivery and, for C-section, within 96 hours
of delivery
• Oral and maxillofacial surgeons
• Orthodontists
• Outpatient emergency room services and associated services
• Outpatient observation room
• Prescription drug (pharmacy)
• Services for the diagnosis of infertility
• Testing and treatment of a sexually transmitted disease
• Testing for AIDS or other HIV-related conditions
• Voluntary planning of the conception and bearing of children
PCCs can contact us to implement a PCC-specific referral bypass
for their managed care members. This is beneficial when you
continually refer to a specific provider.
Blue Cross Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10) 6-15

Blue Plus
Standing Referral Minnesota law provides for a standing referral. Standing referrals
are for longer-term, ongoing care by a specialty provider. They
may be established at any time at the PCCs discretion. Referrals
must be communicated to Blue Plus prior to services being
rendered. PCCs determine the number of referral visits and the
length, up to 365 days.
Mandatory standing referrals to a specialist qualified to treat the
specific condition must be granted, upon request, to a member with
any one of the following conditions.
• A chronic health condition
• A life threatening mental or physical condition
• Pregnancy beyond the first trimester if the member’s plan does
not offer open access benefits to
• Ob/gyn network providers
• A degenerative disease or disability
• Any other condition or disease of sufficient seriousness and
complexity to require treatment by a specialist
Routine standing referrals are still at the discretion of the PCC.
PCCs are not required to authorize a referral to accommodate
personal preference, convenience, or other non-medical reason.
While mandatory-standing referrals must be provided, the PCC
can determine the total number of visits within the 12-month
period based on the member’s medical condition. If the PCC has
the specialist within its clinic/care system, the PCC may request
that the member receive services there. PCCs must communicate
referrals to Blue Plus prior to referred services being rendered.
This law permits specialists, in agreement with the member and
PCC, to provide primary care services, authorize tests and services,
and even make secondary referrals. If the PCC does not grant the
member’s standing referral request, the PCC should inform the
member that he or she can file a complaint with Blue Plus by
calling the telephone number on the back of the member ID card.
6-16 Blue Cross Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10)

Blue Plus
Clarifications of Terms Clear communication between Blue Plus, the PCC, specialist, and
the member is very important. At times, definitions and
understanding of words may differ. To best serve members, a clear
understanding of the meaning of the terms referral, prior
authorization, and preadmission notification is necessary. Listed
are some clarifications and further explanations that are helpful to
fully understand.
Referral:
• A referral is the authorization from the PCC for their members
to seek medical care outside the PCC and receive the highest
level of the member’s benefits.
• A referral does not mean the service is approved for admission
notification or prior authorization, which is separate from the
referral process.
• A referral does not mean the service is eligible under the
member’s contract. Even if the service is referred, the service
must be eligible under the member’s contract to be eligible for
reimbursement.
• Members may think that a service is referred if you tell them
the service is medically necessary. Be clear when you are
referring services.
• A denied referral does not mean that the service is not
medically necessary. It may simply mean that the PCC may be
able to handle the service within its clinic/care system or at a
different referral provider with which the PCC has developed a
relationship.
• Referrals are not created by Blue Plus. Referrals from one
provider to another are established standard practice. We
simply request that it be communicated to us so we may
process claims correctly. For complete information about
Minnesota Health Care Programs, see Chapter 3 of the Blue
Plus Provider Manual.
• A verbal referral is not sufficient.. If the PCC authorized a
referral, it needs to be communicated to us (unless a referral
bypass is in place).
• Referrals should be authorized to the entity billing for the
service (contracting provider), not the individual provider who
is performing the service.
Blue Cross Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10) 6-17

Blue Plus
Clarifications of Terms
(continued)
Prior Authorization:
• A prior authorization does not mean that the service is referred.
If a prior authorization is required and a provider other than the
PCC is performing the service, a referral is also required.
• An approved prior authorization does not mean the service is
covered under the member’s plan. Members’ benefits may
change.
Admission Notification:
• An admission notification does not mean the service is
referred. If an admission notification is required and the PCC
wishes the service to be referred, a referral must be done in
addition to the admission notification. However, when an
admission notification is communicated to us for an inpatient
hospital stay and the admitting physician is part of the
member’s PCC, we will assume that a referral is authorized.
Referral Letter Referral letters are sent as described below. The reverse side of the
referral letter may be used by the specialist to communicate to
your office the results of the services provided.
Referral Letter
(continued)
If the referral is… Then…
To a specialist (not
within the PCC)
For an outpatient
procedure
For an inpatient
procedure
a copy is sent to:
• The referral specialist only if they do not
have access to provider web self-service
• The patient, and
• Your office only if you do not have
access to provider web self-service
a copy is sent to:
• The patient, and
• Your office, only if you do not have
access to provider web self service
no copies are mailed
Please note that if the PCC or the referred specialist has access to
provider web self-service at providerhub.com referral letters will
not be mailed because they have access to the information
electronically.
6-18 Blue Cross Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10)

Sample Patient
Referral Authorization
Letter
If the referral is… Then…
Following is a sample of the referral letter that is mailed in the
above situations.
Blue Plus
Blue Cross Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10) 6-19

Blue Plus
[Date]
[Name of patient]
[Address of patient]
Copy to:
[Name of secondary provider]
Dear [name of patient]
Patient Referral Notice
Patient:
Identification #:
Member #
Relation to subscriber:
Sex: Date of Birth:
Group #
Referral #
This letter is to confirm that your primary care clinic has requested a referral for you to
[insert provider name], for care to be received from ____________ through ________, up to a
maximum of _______ visits.
Your Blue Cross/Blue Plus health plan will pay for its share of the health services described
above, as defined by the terms of your health plan contract, provided that:
1. Your primary care clinic has requested a referral (this letter confirms that this requirement
has been met); and
2. You are otherwise eligible to receive health plan benefits (for example, you are a currently
enrolled member, you have not reached a lifetime or benefit maximum, and your contract
covers the services provided).
Here is a list of other conditions that apply. If you have questions, please call the customer
service number on the back of your health plan member ID card.
• A new referral request must be submitted by your primary care clinic for any care outside
the dates listed or for more than the maximum number of visits noted above.
• This referral is valid only for care provided by [insert provider name].
• If you change your primary care clinic, this referral is no longer valid.
• Any health services related to services excluded in your contract (for example, benefit
exclusions or investigative services) are not covered, even if ordered or provided by your
primary care clinic or the provider to whom you have been referred.
This referral has been made by:
Physician:
Primary Care Clinic:
Clinic Provider #:
Referral care must be provided by:
Provider name:
Provider #:
6-20 Blue Cross Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10)

TO THE REFERRAL SPECIALIST
Blue Plus
You or the primary care clinic must approve any hospitalization, tests or special treatments.
Check with the referring physician to determine the participating hospital the clinic uses. Do not
place yourself or the patient at financial risk by performing services not eligible for coverage
under the patient’s health plan, outside the dates specified or for more than the number of visits
approved on this referral, or by admitting to a facility not authorized by the referring physician.
Special instructions from the referring physician:
Please use the space below to provide a written report of services to the referring physician at:
[address of referring physician]
Blue Cross Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10) 6-21

Blue Plus
Special Member Benefits
Overview This section details some of the special benefits for Blue Plus. It
will assist you in answering some of the questions you may have
regarding the benefits. Information in this provider manual is a
general outline. Provider and member contracts determine benefits.
Chiropractic Benefits Most members have open-access to a Select network chiropractor.
They may receive eligible chiropractic services without a referral
from their PCC. To receive the highest level of the member’s
benefits, the member must use a Select chiropractor.
Continuity of Care
After Facility Discharge
Continuity of Care
After Facility Discharge
(continued)
Durable Medical
Equipment
Patient care can easily become fragmented and compromised as
patients pass from a hospital/facility stay back to the care of their
primary care provider. The Joint Commission of the Accreditation
of Healthcare Organizations (JCAHO) has two Continuum of Care
standards that directly address the follow-up care process of
patients that are discharged. JCAHO states that the need for
appropriate follow-up plans include:
• Providing continuing care based on the patient’s needs
• Exchanging of appropriate information when a patient is
accepted, referred, transferred, or discharged to receive further
care or services
The National Committee for Quality Assurance (NCQA) standards
require that managed care organizations monitor the continuity and
coordination of care that members receive across practices and
provider sites. A smooth transition and continuity of care after
discharge is a need and challenge in every episode of care. Readmissions
can be caused by gaps in the follow-up process.
• Patient role: Patients need to identify a PCC or follow-up
provider who will coordinate their care after facility discharge.
• Hospital/facility role: Hospitals/facilities are encouraged to
develop systems that capture and communicate the patient’s
primary care provider, share information in a timely manner
with the follow-up provider after discharge, provide the patient
with instructions for care after discharge, educate the patient as
needed, and obtain permission from the patient to share
information with the follow-up provider.
• PCC or follow-up provider role: PCCs or follow-up
providers need a process in place to receive and file medical
information into a patient’s clinic chart in a timely manner.
Members can use any Blue Cross and Blue Shield of Minnesota
Aware participating DME provider.
6-22 Blue Cross Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10)

Mental Health and
Chemical Dependency
Services
Blue Plus
Blue Plus members may coordinate their evaluation/management
(E/M) or medication management services through their PCC or
their designated behavioral health provider. E/M and medication
management services performed outside of their PCC or
designated behavioral health provider will require a referral from
the member’s PCC in order to receive the highest level of benefits.
Most groups do not require referrals for claims to process at the
highest level. However, member contracts that require the member
to stay in the Select behavioral health network would need
authorization from Blue Plus to see a provider outside of that
network. PCCs do not need to initiate referrals for patients
requiring mental health/chemical dependency care.
OB/GYN Services State legislation requires open access for specified ob/gyn services
under managed care contracts. When a member obtains eligible
ob/gyn services, she may go to her PCC or elect to seek care from
any ob/gyn network provider without a referral from the PCC and
receive the highest level of her benefits. This benefit is effective
for fully-insured groups. This benefit is optional for self-insured
groups.
OB/GYN Open Access
Additional Services
• Eligible services: The member can go to any ob/gyn network
provider for approved services. The approved services are
considered services billed by a network ob/gyn with a
diagnosis code on our approved list. (See the list later in this
chapter.)
If a member’s needs expand beyond the specified ob/gyn openaccess
benefits, the member needs to be directed back to her
designated PCC or be referred by her PCC in order for the care to
be coordinated by the member’s PCC.
For example, when the ob/gyn provider identifies ovarian cancer
and the member needs to see an oncologist, the member should be
directed back to her PCC, because the oncologist is not an ob/gyn
provider. The open access benefit is only for services billed by
ob/gyn providers.
For those members who have an open access benefit, eligible
inpatient and outpatient hospital and related ob/gyn services are
covered at the member’s highest benefit level. An open access
ob/gyn provider must coordinate the services. We may not be able
to identify these claims during initial processing. Adjustments to
claims may be requested electronically through provider web selfservice,
or by calling Provider Service.
Blue Cross Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10) 6-23

Blue Plus
OB/GYN Open Access
Diagnosis
Please refer to the following list of designated ob/gyn open access
diagnosis codes. Eligible claims submitted with these diagnosis
codes from a specified ob/gyn network provider do not require a
referral, if the patient has the ob/gyn open-access benefit.
Code Description
054.0-054.19 Herpes simplex
078.81-078.89 Other diseases due to viruses and Chlamydiae
079.4 Hum an papillomavirus
079.81. 079.89 Other specified viral and chlamydial infections
099.0-099.9 Syphilis and other venereal disease
112.0-112.9 Candidiasis
127.4 Enterobiasis
131.00-131.9 Trichom oniasis
132.2 Phthirus pubis
174.0-184.9 Malignant neoplasm
217-221.9 Benign neoplasm
233.0-233.9 Carcinoma in situ of breast and genitourinary
system
236.0-236.99 Neoplasm of uncertain behavior of genitourinary
system
239.3 Neoplasm of unspecified nature of breast
239.5 Neoplasm of unspecified nature of other
genitourinary organs
256.0-256.9 Ovarian dysfunction
599.0 Urinary tract infection, site not specified
610.0-611.9 Disorders of breast
614.0-616.9 Inflammatory disease of female pelvic organs
617.0-627.9 Other disorders of female genital tract, infertility
630-677 Complications of pregnancy, childbirth and the
puerperium
698.1 Pruritus of genital organs
752.0-752.9 Congenital anomalies of genital organs
6-24 Blue Cross Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10)

OB/GYN Open Access
Diagnosis (continued)
Code Description
780.01-780.99 General symptoms
788.0-788.9 Symptoms involving urinary system
Blue Plus
789.1-789.9 Other symptoms involving abdomen and pelvis
795.00-795.79 Nonspecific abnormal histological and
immunological findings
996.32 IUD complications
V01.6 Contact with or exposure to venereal diseases
V07.4 Postmenopausal hormone replacement therapy
V10.3 Personal history of malignant neoplasm breast
V10.40-
V10.44
V13.21-
V13.29
Personal history of malignant neoplasm female
genital organs
Personal history of pre-term labor
Other genital system and obstetric disorders
V15.7 Other personal history presenting hazards to
health-contraception
V16.3 Family history of malignant neoplasms of breast
V16.40-
V16.49
Family history of malignant neoplasms of genital
organs
V22.0-V28.9 Nor mal pregnancy
Supervision of high-risk pregnancy
Postpartum care and examination
Contraceptive management
Procreative management
Outcome of delivery
Antenatal screening
V45.51-
V45.52
Presence of intrauterine contraceptive device
Intrauterine contraceptive device
Presence of subdermal contraceptive implant
V61.5-V61.7 Multip arity
Illegitimacy or illegitimate pregnancy
Other unwanted pregnancy
V67.00-V67.9 Follow-up examination
V70.0-V70.9 General medical examination
Blue Cross Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10) 6-25

Blue Plus
OB/GYN Open Access
Diagnosis (continued)
Code Description
V71.5 Observation following alleged rape or seduction
V72.31-
V72.42
Gynecological examination
Pregnancy examination or test, pregnancy
unconfirmed
V74.5 Special screening examination for venereal
disease
V76.10-
V76.19
Special screening for malignant neoplasms of
breast
V76.2 Special screening for malignant neoplasms of
cervix
*Includes all codes (4th or 5th digit) under this category.
Vision Care Fully insured members have direct access to general eye care
services rendered by Aware participating optometrists and
ophthalmologists. Appropriate ophthalmologist services including
eye examinations and Evaluation and Management (E/M)
procedure codes as well as CPT codes 65205, 65210, 65220,
65222, and 68761 are eligible. Some self-insured groups also
include this benefit. Major surgical procedures and follow-up care
will continue to be coordinated through the member’s PCC.
6-26 Blue Cross Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10)

Table of Contents
Chapter 7
BlueCard ®
BlueCard Introduction .............................................................................................................. 7-3
Overview................................................................................................................................7-3
Identifying BlueCard ® Members ...........................................................................................7-3
Definitions.............................................................................................................................. 7-7
How the Program Works .......................................................................................................7-7
BlueCard Service ....................................................................................................................... 7-8
Claims Questions ...................................................................................................................7-8
Benefits and Eligibility ..........................................................................................................7-9
BlueCard Preferred Provider Organization (PPO).................................................................7-9
Prior Authorization and Preadmission Notification.............................................................7-10
BlueCard Claims...................................................................................................................... 7-11
Claims Submission...............................................................................................................7-11
Exclusions............................................................................................................................7-11
Electronic Data Interchange (EDI) Submission...................................................................7-12
Paper Submission.................................................................................................................7-12
Coding.................................................................................................................................. 7-12
Medical Records ..................................................................................................................7-12
Managed Care ......................................................................................................................7-12
Claims Processed by Blue Cross............................................................................................. 7-13
Claims Notification..............................................................................................................7-13
Policies.................................................................................................................................7-13
Adjustments .........................................................................................................................7-13
Claims Processed by the Member’s Plan............................................................................... 7-14
Claims Notification..............................................................................................................7-14
Policies.................................................................................................................................7-14
Adjustments .........................................................................................................................7-14
Appeals ................................................................................................................................7-14
Medical Records....................................................................................................................... 7-15
Overview..............................................................................................................................7-15
Coordination of Benefits (COB) Claims ................................................................................ 7-17
Guidelines ............................................................................................................................7-17
Claim Payment......................................................................................................................... 7-18
Guidelines ............................................................................................................................7-18
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/30/10) 7-1

BlueCard®
Claim Status Inquiry ............................................................................................................... 7-19
Overview..............................................................................................................................7-19
Calls from Members and Others with Claim Questions ...................................................... 7-20
Overview..............................................................................................................................7-20
Traditional Medicare-Related Claims ................................................................................... 7-21
Guidelines ............................................................................................................................7-21
Medicare Advantage Claims through BlueCard .................................................................. 7-23
Overview..............................................................................................................................7-23
Types of Medicare Advantage Plans ...................................................................................7-24
Eligibility Verification.........................................................................................................7-25
Medicare Advantage Claims Submission ............................................................................7-26
Reimbursement for Medicare Advantage PPO, HMO, POS ...............................................7-26
Reimbursement for Medicare Advantage Private-Fee-for-Service (PFFS).........................7-28
7-2 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/30/10)

BlueCard Introduction
BlueCard®
Overview The BlueCard Program links health care providers and the
independent Blue plans* across the country and abroad with a
single electronic network for professional, outpatient, inpatient
claims processing and reimbursement. The program allows Blue
Cross providers in every state to submit claims for Blue Cross
members to their local Blue plan, eliminating the need to track
receivables from multiple Blue plans.
Identifying BlueCard ®
Members
Through the BlueCard program, you can submit claims directly to
Blue Cross for your patients who have coverage with a Blue plan
other than Blue Cross. Blue Cross will be your contact for medical
records submission, claims payment, problem resolution and
adjustments.
BlueCard is a national program that enables Blue plan members to
obtain healthcare services wherever they are in the United States.
The program links participating healthcare providers with all the
Blue Cross plans across the nation through a single electronic
network for claims processing and reimbursement. Additionally,
the program links providers in more than 200 countries and
territories worldwide.
* Each Blue plan is an independent licensee of the Blue Cross and
Blue Shield Association.
BlueCard members can easily be identified by the three alpha
characters preceding their identification (ID) number and the
suitcase logos; either empty, or with letters “PPO” inside, on their
cards. Although the format of the identification number may vary
from plan to plan, you can always recognize the trusted Blue Cross
and Blue Shield emblems. Providers are encouraged to make a
copy of both the front and back of the member’s ID card. Please
enter the patient’s ID number on claims submitted exactly as it
appears on the card, including the alpha prefix.
Although all Blue plans participate in the BlueCard Program, there
are some programs that are exempt such as Medicaid. If the patient
is carrying a current Blue Cross ID card and there is no suitcase
logo on the card, but there is an alpha prefix, claims should still be
filed to Blue Cross as any other claim. We will facilitate the
processing of that claim on your behalf.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/30/10) 7-3

BlueCard®
Identifying BlueCard ®
Members (continued)
Important facts concerning member IDs:
• A correct member ID number includes the alpha prefix (first
three positions) and all subsequent characters, up to 17
positions total. This means that you may see cards with ID
numbers between 6 and 14 numbers/letters following the alpha
prefix.
• Do not add/delete characters or numbers within the member
ID.
• Do not change the sequence of the characters following the
alpha prefix.
• The alpha prefix is critical for the electronic routing of specific
HIPAA transactions to the appropriate Blue plan.
• Members who are part of the Federal Employee Program will
have the letter "R" in front of their member ID number.
Examples of ID numbers:
ABC1234567
Alpha
Prefix
ABC1234H567
Alpha
Prefix
ABC12345678901234
Alpha
Prefix
As a provider servicing out-of-area members, you may find the
following tips helpful:
• Ask the member for the most current ID card at every visit.
Since new ID cards may be issued to members throughout the
year, this will ensure that you have the most up to date
information in your patient’s file.
• Verify with the member that the ID number on the card is not
his/her Social Security number. If it is, call the BlueCard
eligibility line 1-800-676-BLUE to verify the ID number.
• Make a copy of the front and back of the member’s ID card
and pass this key information on to your billing staff.
NOTE: Member ID numbers must be reported exactly as shown
on the ID card and must not be changed or altered. Do not add or
omit any characters from the member ID numbers.
7-4 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/30/10)

Identifying BlueCard ®
Members (continued)
Alpha Prefix
BlueCard®
The three-character alpha prefix at the beginning of the member’s
identification number is the key element used to identify and
correctly route claims. The alpha prefix identifies the Blue plan or
national account to which the member belongs. It is critical for
confirming a patient’s membership and coverage.
To ensure accurate claim processing, it is critical to capture all ID
card data. If the information is not captured correctly, you may
experience a delay with the claim processing. Please make copies
of the front and back of the ID card, and pass this key information
to your billing staff.
Do not make up alpha prefixes.
Do not assume that the member’s ID number is the Social Security
number. All Blue plans replaced Social Security numbers on
member ID cards with an alternate, unique identifier.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/30/10) 7-5

BlueCard®
Identifying BlueCard ®
Members (continued)
Sample ID Cards
7-6 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/30/10)

BlueCard®
Definitions Terms that you will hear when dealing with BlueCard members:
How the Program
Works
Term Definition
BlueCard
Program
A program that enables members to obtain health
care services while traveling or living in another
licensee’s service area and receive the benefits of
their Blue Cross contract.
The BlueCard Program is designed to work as follows:
1. A patient having Blue Cross coverage receives services at your
office.
2. You submit the claim to Blue Cross.
3. Blue Cross will price the claim according to your contract and
send the claim electronically to the member’s plan for benefit
determination.
4. The member’s plan applies the member’s benefits and sends
the information back to Blue Cross. They will communicate
the outcome of the claim to the member.
5. Blue Cross will send the electronic remittance advice and
payment for eligible benefits to you.
6. Deductible and coinsurance collection from members can
occur once the claim is adjudicated and you receive your
electronic remittance advice (835) or view your remittance
advice on provider web self service.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/30/10) 7-7

BlueCard®
BlueCard Service
Claims Questions Provider web self service should be used to check the status of a
BlueCard claim. Enter only the member’s Blue Cross ID number
without the alpha prefix and the dates of service.
Claim status is also available by calling Blue Cross provider
services. Status is available via a FAX or automated voice
response.
We encourage you to self service so that our provider services staff
is available to assist with any questions or concerns regarding
claims, claims payment and problem resolution.
Please pay special attention to the phone prompts to ensure
connection to the correct representative within Blue Cross provider
services.
BlueCard claims cannot be viewed on BLUELINE.
7-8 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/30/10)

BlueCard®
Benefits and Eligibility You may contact the BlueCard eligibility number for benefits and
eligibility 1-800-676-BLUE (2583) for other plans’ members. If
the automated system on the BlueCard eligibility line cannot
identify the three digit alpha prefix that is being stated, after the
second failed attempt, you will automatically be transferred to a
BlueCard agent. The BlueCard agent will need one of the
following answers to be accurate in order to validate:
BlueCard Preferred
Provider Organization
(PPO)
1. Alpha prefix
2. Plan code
3. Name of Blue Cross plan
4. Employee name
5. State in which the member’s plan is located (can be found on
the back of the member’s ID card)
You will be asked for the alpha prefix on the ID card and will then
be transferred to the member’s plan. They will provide the
information requested.
You may also submit a 270 request via provider web self service
for benefits and eligibility. In addition, you could send an
electronic request (EDI) via Availity, but you must register to do
that. * Be sure to include:
1. ID number, including alpha prefix
2. Patient first and last name
3. Date of birth
* Availity registration information: availity.com.
The BlueCard PPO program is a national program that offers
members the PPO level of benefits when outside their Blue plan
area and they obtain services from a physician or hospital
designated as a PPO provider.
You will immediately recognize these PPO members by the
special “PPO in a suitcase” logo on their ID card.
Blue Cross utilizes the Aware® provider network as our BlueCard
PPO network. Members can access information about providers in
this network via the toll free number: 1-800-810-BLUE (2583) or
on the BlueCard website, bcbs.com.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/30/10) 7-9

BlueCard®
Prior Authorization and
Preadmission
Notification
Any required prior authorizations and/or preadmission
notifications for members covered by a Blue plan besides Blue
Cross must go through the member’s plan. In these cases, the
member is responsible for obtaining prior authorizations and
preadmission notifications. However, as a courtesy, you may
contact their plan directly for authorizations using the phone
number listed on the back of the member’s ID card or by accessing
the Medical Policy/Precertification/Prior Authorization Router via
providers.bluecrossmn.com
When the length of an inpatient hospital stay extends past the
previously approved length of stay, any additional days must be
approved. Failure to obtain approval for the additional days may
result in claims processing delays and potential payment denials. If
prior authorization or preadmission notification is not obtained and
is required by the patient’s contract, the patient will be liable for
the charges. To avoid delays in the processing of your claims,
please assure the necessary approval(s) are obtained in advance of
services being rendered.
7-10 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/30/10)

BlueCard Claims
BlueCard®
Claims Submission Be sure to include the complete alpha prefix and ID number when
submitting claims. The alpha prefix should have at least three
letters, but may have more, as a portion of the ID number. You
must submit these claims directly to Blue Cross (see exclusions
below). Once Blue Cross processes the claim you will receive
claims information and any appropriate payment on your
electronic remittance advice (835).
Some members have been issued identification cards with an alpha
prefix, but for various reasons the claims cannot process through
the BlueCard program. You should still submit these claims to
Blue Cross and we will forward them to the member’s plan for
processing. We will notify you of this on your weekly electronic
remittance advice (835). Even though you have been notified that
the member’s plan will be processing the patient’s claim directly,
you should still direct all inquiries regarding that claim to Blue
Cross. We will act as your single point of contact for that claim.
See Claims Processed by the Member’s Plan, later in this chapter.
Submit the claim to Blue Cross when:
• You provide care to a member from Minnesota, or
• You provide care to a member who has coverage with a Blue
plan in another part of the country and you are located in
Minnesota.
Note: Providers who have agreements with both Blue Cross and
another Blue plan should consult with Blue Cross about the
handling of non-Minnesota member claims.
Exclusions The following are exclusions to the BlueCard program. Please
submit these claims as instructed on the ID card:
• Dental services covered under a stand-alone dental contract.
• Drug claims billed by a pharmacy.
• Federal Employee Program (FEP).
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/30/10) 7-11

BlueCard®
Electronic Data
Interchange (EDI)
Submission
For Electronic Data Interchange submission:
• All BlueCard claims must be sent electronically using the
Minnesota Uniform Companion Guide. Refer to Chapter 8,
Claims Filing, for more information regarding electronic
submission of claims.
• Be sure to include the alpha prefix with no spaces between the
prefix and the ID number.
• Be sure to send the subscriber’s ID number as it appears on the
ID card.
• Be sure to include accurate subscriber and patient information.
• Be sure to use the correct patient relationship.
Paper Submission • Effective July 15, 2009, all claims from Minnesota providers
must be submitted electronically due to Minnesota Statute -
62J.536. (Provider Quick Points QP7-09). Refer to Chapter 8,
Claims Filing, for more information regarding claims
submission.
Coding Code claims as you would for local claims. Refer to Chapter 11,
Coding Policies and Guidelines, for more coding information.
Medical Records There are times when the member’s plan will require medical
records to review the BlueCard claim. These requests should come
to you from us. If the member’s plan contacts you directly, please
forward all requested records to Blue Cross. We will coordinate
with the member’s plan. Always include the member’s Blue Cross
ID number with the alpha prefix. Participating providers are not
allowed to bill Blue Cross for medical records. This is part of your
provider agreement and requests for payment will not be honored.
Managed Care It is generally the responsibility of the member’s plan to approve
or deny claims. This is also true for managed care reviews.
Contrary to your standard provider contract, you will not be
responsible, and the patient may be billed as indicated on your
provider remit, for the following denials when applicable to a
member with coverage through a Blue plan other than Blue Cross:
• Investigative services
• Care management charges or penalties
• Medical necessity
7-12 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/30/10)

Claims Processed by Blue Cross
BlueCard®
Claims Notification Blue Cross will issue claims payment and notification directly to
you as a participating provider on our standard electronic
remittance advice (835) or by posting your remittance to provider
web self service. Statements have been sorted to provide a separate
section for BlueCard business for providers billing on the CMS-
1500 form or the 837P electronic format. For those providers
billing on the CMS-1450 (UB-92) or the 837I electronic format,
the claims will not be separated.
Your patients’ Explanation of Benefits (EOB) will be issued to
them by the home plan. Should there be a discrepancy between the
patient’s EOB and your remittance, please send a copy of both to
Blue Cross provider services for review.
Policies When a BlueCard claim is received by Blue Cross the following
procedures must be followed:
• Providers must comply with all standard contractual
procedures. Patients cannot be billed as follows, except as
otherwise allowed by law:
• prior to the submission of the claim
• for any contractual reductions, or
• prior to the finalization of their claims
• Providers will not be responsible, and patients may be billed,
for the following denials by the member’s plan:
• Investigative services
• Care management charges or penalties
• Medical necessity
• Non-covered services
• BlueCard program exempt services (stand-alone dental,
drug claims billed by a pharmacy)
Adjustments Contact us if an adjustment is required. We do need to work with
the member’s plan for adjustments; however, your workflow
should not be different. You may continue to contact Blue Cross
provider services for any questions or status on adjustments for
BlueCard claims.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/30/10) 7-13

BlueCard®
Claims Processed by the Member’s Plan
Claims Notification If the member’s plan is processing the claim because it cannot go
through BlueCard processing, you will be notified on your weekly
electronic remittance advice (835).
The claim will be documented and the remark message will read,
“This claim has been forwarded to the subscriber’s home plan for
processing.” Contact Blue Cross for any information regarding
this claim, we will contact the member’s plan. You may bill the
member for these services.
Policies Since this is not a BlueCard eligible claim, your Blue Cross
provider agreement generally does not apply.
Adjustments Communicate your adjustment request with Blue Cross. We will
contact the member’s plan on your behalf.
Appeals Please refer to Chapter 10 for information regarding appeals.
7-14 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/30/10)

Medical Records
Overview Medical Records
BlueCard®
Blue plans around the country have made improvements to the
medical records process to make it more efficient. We now are
able to send and receive medical records electronically among
each other. This new method significantly reduces the time it takes
to transmit supporting documentation for our out of area claims,
reduces the need to request records multiple times and eliminates
lost or misrouted records.
Under what circumstances may the provider get requests for
medical records for out-of-area members?
1. As part of the pre-authorization process—If you receive
requests for medical records from other Blue plans prior to
rendering services, as part of the pre-authorization process,
you will be instructed to submit the records directly to the
member’s plan that requested them. This is the only
circumstance where you would not submit them to Blue Cross
of Minnesota.
2. As part of claim review and adjudication—These requests will
come from Blue Cross of Minnesota in a form of a letter
requesting specific medical records and including instructions
for submission.
BlueCard medical record process for claim review
1. An initial communication, generally in the form of a letter,
should be received by your office requesting the needed
information.
2. A remittance may be received by your office indicating the
claim is being denied pending receipt and review of records.
Occasionally, the medical records you submit might cross in
the mail with the remittance advice for the claim indicating a
need for medical records. A remittance advice is not a
duplicate request for medical records. If you submitted medical
records previously, but received a remittance advice indicating
records were still needed, please contact Blue Cross of
Minnesota to ensure your original submission has been
received and processed. This will prevent duplicate records
being sent unnecessarily.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/30/10) 7-15

BlueCard®
Overview (continued) 3. If you received only a remittance advice indicating records are
needed, but you did not receive a medical records request
letter, contact Blue Cross of Minnesota to determine if the
records are needed from your office.
4. Upon receipt of the information, the claim will be reviewed to
determine the benefits.
Helpful ways you can assist in timely processing of medical
records
1. If the records are requested following submission of the claim,
forward all requested medical records to Blue Cross of
Minnesota.
2. Follow the submission instructions given on the request, using
the specified address or FAX number. The address or FAX
number for medical records may be different than the address
you use to submit claims.
3. Include the cover letter you received with the request when
submitting the medical records. This is necessary to make sure
the records are routed properly once received by Blue Cross of
Minnesota.
4. Please submit the information to Blue Cross of Minnesota as
soon as possible to avoid further delay.
5. Only send the information specifically requested. Frequently,
complete medical records are not necessary.
6. Please do not proactively send medical records with the claim.
Unsolicited claim attachments may cause claim payment
delays.
7-16 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/30/10)

Coordination of Benefits (COB) Claims
BlueCard®
Guidelines Coordination of benefits (COB) refers to how we ensure members
receive full benefits and prevent double payment for services when
a member has coverage from two or more sources. The member’s
contract language explains the order for which entity has primary
responsibility for payment and which entity has secondary
responsibility for payment.
If you discover the member is covered by more that one health
plan, and:
• Blue Cross or any other Blue plan is the primary payer, submit
other carrier’s name and address with the claim to Blue Cross
of Minnesota. If you do not include the COB information with
the claim, the member’s Blue plan will have to investigate the
claim. This investigation could delay your payment or result in
a post-payment adjustment, which will increase your volume
of bookkeeping.
• Other non-Blue health plan is primary and Blue Cross
Minnesota or any other Blue plan is secondary, submit the
claim to Blue Cross of Minnesota only after receiving payment
from the primary payer, including the explanation of payment
from the primary carrier. If you do not include the COB
information with the claim, the member’s Blue plan will have
to investigate the claim. This investigation could delay your
payment or result in a post-payment adjustment, which will
increase your volume of bookkeeping.
Coordination of Benefits Questionnaire
To streamline our claims processing and reduce the number of
denials related to coordination of benefits, a COB questionnaire is
now available to you at providers.bluecrossmn.com that will help
you and your patients avoid potential claim issues. The COB form
is in the “Other Forms” section in the Forms and Publications area.
When you see any Blue members and you are aware that they
might have other health insurance coverage (that is,. Medicare),
give a copy of the questionnaire to them during their visit. Ask
them to complete the form and send it to the Blue plan through
which they are covered as soon as possible after leaving your
office. Members will find the address on the back of their member
identification card or by calling the customer service numbers
listed on the back of the card. Collecting COB information from
members before you file their claim eliminates the need to gather
this information later, thereby reducing processing and payment
delays.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/30/10) 7-17

BlueCard®
Claim Payment
Guidelines • If you have not received payment for a claim, do not resubmit
the claim; it will be denied as a duplicate. This also causes
member confusion because of multiple Explanations of
Benefits (EOBs). Blue Cross of Minnesota’s standard time for
claims processing is 17 days. However, claim processing times
at various Blue plans vary.
• If you do not receive your payment or a response regarding
your payment, please call Blue Cross of Minnesota provider
services at (651) 662-5200 or 1-800-262-0820 or visit our
website at providerhub.com to check the status of your claim.
• In some cases, a member’s Blue plan may pend a claim
because medical review or additional information is necessary.
When resolution of a pended claim requires additional
information from you, Blue Cross of Minnesota may either ask
you for the information or give the member’s plan permission
to contact you directly.
7-18 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/30/10)

Claim Status Inquiry
Overview Blue Cross of Minnesota is your single point of contact for all
claim inquiries.
Claim status inquires can be done by:
BlueCard®
• Phone—call provider service at (651) 662-5200 or
1-800-262-0820.
• Electronically—send a HIPAA transaction 276 (claim status
inquiry) to Blue Cross of Minnesota via EDI.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/30/10) 7-19

BlueCard®
Calls from Members and Others with Claim
Questions
Overview If members contact you, advise them to contact their Blue plan and
refer them to their ID card for a customer service number.
The member’s plan should not contact you directly regarding
claims issues, but if the member’s plan contacts you and asks you
to submit the claim to them, refer them to Blue Cross of
Minnesota.
7-20 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/30/10)

Traditional Medicare-Related Claims
Guidelines The following are guidelines for the processing of traditional
Medicare-related claims:
BlueCard®
• when Medicare is primary payer, submit claims to your local
Medicare intermediary.
• as of January 1, 2008, all Blue claims are set up to
automatically crossover to the member’s Blue plan after being
adjudicated by the Medicare intermediary.
How do I submit Medicare primary / Blue plan secondary claims?
• For members with Medicare primary coverage and Blue plan
secondary coverage, submit claims to your Medicare
intermediary and/or Medicare carrier.
• When submitting the claim, it is essential that you enter the
correct Blue plan name as the secondary carrier. This may be
different from the local Blue plan. Check the member’s ID
card for additional verification.
• Include the alpha prefix as part of the member identification
number. The member’s ID will include the alpha prefix in the
first three positions. The alpha prefix is critical for confirming
membership, coverage and key to facilitating prompt
payments.
When you receive the remittance advice from the Medicare
intermediary, look to see if the claim has been automatically
forwarded (crossed over) to the Blue plan:
• If the remittance advice indicates that the claim was crossed
over, Medicare has forwarded the claim on your behalf to the
appropriate Blue plan and the claim is in process. There is no
need to resubmit that claim to Blue Cross of Minnesota.
• If the remittance advice indicates that the claim was not
crossed over, submit the claim to Blue Cross of Minnesota
with the Medicare remittance advice.
• In some cases, the member identification card may contain a
COBA ID number. If so, be certain to include that number on
your claim.
• For claim status inquiries, contact Blue Cross of Minnesota
through provider web self service.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/30/10) 7-21

BlueCard®
Guidelines (continued) When should I expect to receive payment?
Claims submit to the Medicare intermediary will be crossed over
to the Blue plan only after they have been processed. This process
may take up to 14 business days. This means that the Medicare
intermediary will be releasing the claim to the Blue plan for
processing about the same time you receive the Medicare
remittance advice. As a result, it may take an additional 14-30
business days for you to receive payment from the Blue plan.
What should I do in the meantime?
If you submitted the claim to the Medicare intermediary/carrier,
and haven’t received a response to your initial claim submission,
don’t automatically submit another claim. Rather, you should:
• review the automated resubmission cycle on your claim
system.
• wait 30 days.
• check claims status before resubmitting.
Sending another claim, or having your billing agency resubmit
claims automatically, slows down the claim payment process and
creates confusion for the member.
Who do I contact if I have questions or to check claim status?
If you have questions, please contact Blue Cross of Minnesota
through provider web self service.
7-22 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/30/10)

Medicare Advantage Claims through BlueCard
Overview “Medicare Advantage” (MA) is the program alternative to
standard Medicare Part A and Part B fee-for-service coverage;
generally referred to as “traditional Medicare.”
BlueCard®
MA offers Medicare beneficiaries several product options (similar
to those available in the commercial market), including health
maintenance organization (HMO), preferred provider organization
(PPO), point-of-service (POS) and private fee-for-service (PFFS)
plans.
All Medicare Advantage plans must offer beneficiaries at least the
standard Medicare Part A and B benefits, but many offer
additional covered services as well (for example, enhanced vision
and dental benefits).
In addition to these products, Medicare Advantage organizations
may also offer a Special Needs Plan (SNP), which can limit
enrollment to subgroups of the Medicare population in order to
focus on ensuring that their special needs are met as effectively as
possible.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/30/10) 7-23

BlueCard®
Types of Medicare
Advantage Plans
Medicare Advantage HMO
A Medicare Advantage HMO is a Medicare managed care option
in which members typically receive a set of predetermined and
prepaid services provided by a network of physicians and
hospitals. Generally (except in urgent or emergency care
situations), medical services are only covered when provided by in
network providers. The level of benefits and the coverage rules
may vary by Medicare Advantage plan.
Medicare Advantage POS
A Medicare Advantage POS program is an option available
through some Medicare HMO programs. It allows members to
determine—at the point of service—whether they want to receive
certain designated services within the HMO system, or seek such
services outside the HMO’s provider network (usually at greater
cost to the member). The Medicare Advantage POS plan may
specify which services will be available outside of the HMOs
provider network.
Medicare Advantage PPO
A Medicare Advantage PPO is a plan that has a network of
providers, but unlike traditional HMO products, it allows members
who enroll access to services provided outside the contracted
network of providers. Required member cost-sharing may be
greater when covered services are obtained out of network.
Medicare Advantage PPO plans may be offered on a local or
regional (frequently multi-state) basis. Special payment and other
rules apply to regional PPOs.
Medicare Advantage PFFS
A Medicare Advantage PFFS plan is a plan in which the member
may go to any Medicare approved doctor or hospital that accepts
the plan’s terms and conditions of participation. Acceptance is
“deemed” to occur where the provider is aware, in advance of
furnishing services, that the member is enrolled in a PFFS product
and where the provider has reasonable access to the terms and
conditions of participation.
The Medicare Advantage organization, rather than the Medicare
program, pays physicians and providers on a fee-for-services basis
for services rendered to such members. Members are responsible
for cost-sharing, as specified in the plan.
7-24 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/30/10)

Types of Medicare
Advantage Plans
(continued)
Medicare Advantage PFFS varies from the other Blue products
you might currently participate in:
BlueCard®
• You can see and treat any Medicare Advantage PFFS member
without having a contract with Blue Cross.
• If you do provide services, you will do so under the terms and
conditions of that member’s Blue plan.
• Please refer to the back of the member’s ID card for
information on accessing the plan’s terms and conditions. You
may choose to render services to a MA PFFS member on an
episode of care (claim-by-claim) basis.
• MA PFFS terms and conditions may vary for each Blue Cross
a plan and we advise that you review them before servicing
MA PFFS members.
• Submit your MA PFFS claims to Blue Cross.
Medicare Advantage Medical Savings Account (MSA)
Medicare Advantage Medical Savings Account (MSA) is a
Medicare health plan option made up of two parts. One part is a
Medicare MSA Health Insurance Policy with a high deductible;
The other part is a special savings account where Medicare
deposits money to help members pay their medical bills.
Eligibility Verification • Verify eligibility by contacting 1-800-676-BLUE (2583) and
providing an alpha prefix or by submitting an electronic
inquiry to www.providerhub.com and providing the alpha
prefix.
• If you experience difficulty obtaining eligibility information,
please record the alpha prefix and report it to Blue Cross of
Minnesota.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/30/10) 7-25

BlueCard®
Medicare Advantage
Claims Submission
Reimbursement for
Medicare Advantage
PPO, HMO, POS
• Submit all Medicare Advantage claims to Blue Cross.
• Do not bill Medicare directly for any services rendered to a
Medicare Advantage member.
• Payment will be made directly by a Blue plan.
Based upon the Centers for Medicare and Medicaid Services
(CMS) regulations, if you are a provider who accepts Medicare
assignment and you render services to a Medicare Advantage
member for whom you have no obligation to provide services
under your contract with a Blue plan, you will generally be
considered a non-contracted provider and be reimbursed the
equivalent of the current Medicare allowed amount for all covered
services (i.e., the amount you would collect if the beneficiary were
enrolled in traditional Medicare).
MedicareBlue PPO and Group MedicareBlue PPO are regional
Medicare Advantage plans with a Medicare contract.
MedicareBlue PPO and Group MedicareBlue PPO coverage is
separately issued by one of the following plans:
• Wellmark Blue Cross Blue Shield of Iowa
• Blue Cross Blue Shield of Minnesota
• Blue Cross Blue Shield of Montana
• Blue Cross Blue Shield of Nebraska
• Blue Cross Blue Shield of North Dakota
• Wellmark Blue Cross Blue Shield of South Dakota
• Blue Cross Blue Shield of Wyoming.
Special payment rules apply to hospitals and certain other entities
(e.g., skilled nursing facilities) that are non-contracted providers.
Providers should make sure they understand the applicable
Medicare Advantage reimbursement rules.
Other than the applicable member cost-sharing amounts,
reimbursement is made directly by a Blue plan or its branded
member’s affiliate. In general, you may collect only the applicable
cost-sharing (e.g., copayment or coinsurance) amount from the
member at the time of service, and may not otherwise charge or
balance bill the member.
Note: Enrollee payment responsibilities can include more than
copayments (e.g., deductibles).
Please review the remittance notice concerning Medicare
Advantage plan payment, member’s payment responsibility and
balance billing limitations.
7-26 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/30/10)

Reimbursement for
Medicare Advantage
PPO, HMO, POS
(continued)
BlueCard®
Plan Contract: services for local and regional Blue Medicare
Advantage members
Situation below is where the provider has a contract with Blue
Cross of Minnesota for MA and provides service to a Blue Cross
of Minnesota Blue MA member.
If you are a provider who accepts Medicare assignment and you
render services to a local or regional Medicare Advantage member
for whom you have an obligation to provide services under your
contract with a Blue plan, you will be considered a contracted
provider and be reimbursed per the contractual agreement.
Providers should make sure they understand the applicable
Medicare Advantage reimbursement rules and their individual
plan contractual arrangements.
Other than the applicable member cost-sharing amounts,
reimbursement is made directly by a Blue plan. In general, you
may collect only the applicable cost-sharing (e.g., copayment or
coinsurance) amounts from the member at the time of service, and
may not otherwise charge or balance bill the member.
Please review the remittance notice concerning Medicare
Advantage plan payment, member’s payment responsibility and
balance billing limitations.
Plan Contract: Services for out-of-area Medicare Advantage
Blue members
Situation below is where the provider has a contract with Blue
Cross of Minnesota for local and regional MA and provides
services for out-of-area Blue MA members.
If you are a provider who accepts Medicare assignment, has a Blue
plan contract to provide services for local and regional Medicare
Advantage enrollees only, and you render services to out-of-area
Blue Medicare Advantage members, you will be reimbursed at the
Medicare allowed amount (i.e., the amount you would collect if
the beneficiary were enrolled in traditional Medicare). Providers
should make sure they understand the applicable Medicare
Advantage reimbursement rules and their individual plan
contractual arrangements.
Other than the applicable member cost-sharing amounts,
reimbursement is made directly by a Blue plan. In general, you
may collect only the applicable cost-sharing (e.g., copayment or
coinsurance) amounts from the member at the time of service and
may not otherwise charge or balance bill the member.
Please review the remittance notice concerning Medicare
Advantage plan payment, member’s payment responsibility and
balance billing limitations.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/30/10) 7-27

BlueCard®
Reimbursement for
Medicare Advantage
Private-Fee-for-Service
(PFFS)
Services for out-of-area Blue Medicare Advantage PFFS
members
Situation below is where the provider renders services for out-ofarea
MA PFFS members.
If you have rendered services for a Blue out-of-area Medicare
Advantage PFFS member but are not obligated to provide services
to such member under a contract with a Blue plan, you will
generally be reimbursed the Medicare allowed amount for all
covered services (i.e., the amount you would collect if the
beneficiary were enrolled in traditional Medicare). Providers
should make sure they understand the applicable Medicare
Advantage reimbursement rules.
Other than the applicable member cost-sharing amounts,
reimbursement is made directly by a Blue plan. In general, you
may collect only the applicable cost-sharing (e.g., copayment or
coinsurance) amounts from the member at the time of service and
may not otherwise charge or balance bill the member.
Please review the remittance notice concerning Medicare
Advantage plan payment, member’s payment responsibility and
balance billing limitations.
7-28 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/30/10)

Table of Contents
Chapter 8
Claims Filing
Administrative Simplification...................................................................................................8-4
Introduction............................................................................................................................8-4
Web-based Claim Submission, Eligibility, and Remittance Tool ......................................... 8-4
Pharmacy and Dental Claims................................................................................................. 8-4
Pre-system Edits.....................................................................................................................8-5
Claims with Attachments....................................................................................................... 8-5
Claims with Coordination of Benefits ................................................................................... 8-7
Medicare/Uniform Companion Guide Coding Alignment ..................................................8-10
Questions..............................................................................................................................8-11
1500 HICF Form...................................................................................................................... 8-12
Professional Claim Submission ...........................................................................................8-12
1500 HICF Manual ..............................................................................................................8-12
About the NUCC..................................................................................................................8-12
UB-04 (CMS 1450) Form......................................................................................................... 8-13
Institutional Claim Submission............................................................................................ 8-13
UB-04 Manual ..................................................................................................................... 8-13
About the NUBC..................................................................................................................8-13
Ordering Forms and Manuals ................................................................................................ 8-14
HCPCS, CPT and ICD-9-CM Manuals ...............................................................................8-14
HIPAA Implementation Guides........................................................................................... 8-14
Minnesota Uniform Companion Guides..............................................................................8-14
1500 HICF (CMS-1500) UB-04 (CMS-1450) Forms .........................................................8-14
UB-04 Manual ..................................................................................................................... 8-14
1500 HICF Manual ..............................................................................................................8-14
Professional/837P Billing......................................................................................................... 8-15
Zero Billed Charges .............................................................................................................8-15
Linking and Sequencing ...................................................................................................... 8-15
Place of Service Codes......................................................................................................... 8-15
Site of Service......................................................................................................................8-15
Freestanding Ambulatory Surgery Center Billing ............................................................... 8-16
K3 Segment Usage Instructions for Condition Codes ......................................................... 8-17
Institution (837I) /Facility Billing........................................................................................... 8-18
Claim Format Regulations ...................................................................................................8-18
Procedure Code Regulations................................................................................................ 8-19
Revenue Codes (FL 42) .......................................................................................................8-19
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (05/10/12) 8-1

Claims Filing
HCPCS/ Accommodation Rates/HIPPS Rate Codes (FL 44)..............................................8-19
Duplicate Billing..................................................................................................................8-19
Treatment Room ..................................................................................................................8-20
Observation Room ............................................................................................................... 8-20
Clinic Charges......................................................................................................................8-20
Transfer Case .......................................................................................................................8-20
Single facility claim submission ..........................................................................................8-21
Zero Billed Charges .............................................................................................................8-22
Lactation Education .............................................................................................................8-22
0636 Drugs Requiring Prior Auth........................................................................................ 8-22
Present on Admission (POA)............................................................................................... 8-22
Claims Filing............................................................................................................................. 8-24
Timely Filing .......................................................................................................................8-24
Claims Crossover for Medicare and Medicare Supplement ................................................ 8-24
Medicare Crossover ............................................................................................................. 8-25
837I Crossover Information................................................................................................. 8-25
837P Crossover Information................................................................................................ 8-25
Duplicate Claims.................................................................................................................. 8-26
Submission of Claims .......................................................................................................... 8-26
Cancel/Void and Replacement Claims ................................................................................ 8-27
Release of Medical Records.................................................................................................8-32
Provider Assistance Requested............................................................................................ 8-32
Medical Records Management Process Improvement.........................................................8-32
Verify Member Identity .......................................................................................................8-32
Verifying Patient Eligibility................................................................................................. 8-33
Basic Character Set Values in the Electronic Transaction................................................... 8-34
Claim Service Dates Restricted to Same Calendar Month .................................................. 8-35
Reporting MNCare and Sales Tax ....................................................................................... 8-36
Rural Health Clinics and Federally Qualified Health Centers............................................ 8-37
Billing for Medicare Primary............................................................................................... 8-37
Billing Other Than Medicare Primary .................................................................................8-37
Coordination of Benefits (COB) ............................................................................................. 8-38
Overview..............................................................................................................................8-38
Primacy Determination ........................................................................................................ 8-38
Coordination of Benefits Types .............................................................................................. 8-39
Workers’ Compensation ...................................................................................................... 8-40
No-fault Auto.......................................................................................................................8-40
Subrogation..........................................................................................................................8-40
TEFRA.................................................................................................................................8-41
DEFRA ................................................................................................................................8-41
COBRA................................................................................................................................8-41
OBRA ..................................................................................................................................8-41
Non-Physician Health Care Practitioners ............................................................................. 8-42
Introduction..........................................................................................................................8-42
Eligibility Criteria ................................................................................................................8-42
Definitions............................................................................................................................8-42
8-2 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (05/10/12)

Claims Filing
Employment.........................................................................................................................8-43
Incident To...........................................................................................................................8-43
Direct Supervision ............................................................................................................... 8-44
General Supervision.............................................................................................................8-44
Collaboration/ Independent Practice....................................................................................8-44
Chiropractic Doctors and Multidisciplinary Clinics............................................................8-44
Surgical Technicians............................................................................................................8-45
Mid-level Practitioners.........................................................................................................8-45
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (05/10/12) 8-3

Claims Filing
Administrative Simplification
Introduction Minnesota Statute 62J.536, requires health care providers and
group purchasers (payers, health plans) to exchange eligibility
requests, claims and remittances electronically using standard
formats. The intent of the law is to reduce costs, simplify and
speed up health care transactions, and to give providers and health
plans one set of rules to follow for electronic transactions. This
statute applies to all health care providers in Minnesota, regardless
of participating status.
Web-based Claim
Submission, Eligibility,
and Remittance Tool
Pharmacy and Dental
Claims
Blue Cross and Blue Shield of Minnesota (Blue Cross) offers a nocost,
web-based tool through Availity to comply with the
Minnesota Statute 62J.536. Availity, an independent company,
also provides no-cost solutions to obtain eligibility and benefits as
well as viewing your remittance information. Availity, an
independent company, is a one stop shop that optimizes
information exchange between multiple heath care stakeholders
through a single secure network. Providers may also take
advantage of a range of optional, value-added services for a
nominal cost. For more information contact Availity at
availity.com to register for their no-cost web-based tools.
The requirement to submit all claims electronically includes dental
and pharmacy formatted claim types. Blue Cross is completing
system changes to accept and properly adjudicate these electronic
claim types. Due to the complexity of the changes and need for
extensive testing, Blue Cross can not accept dental formatted or
pharmacy formatted electronic claims at this time. Pharmacy and
dental providers should continue to submit these claim types on
paper until notified by Blue Cross.
8-4 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (05/10/12)

Claims Filing
Pre-system Edits Blue Cross has aligned our pre-system edits with the rules
published in the Uniform Claims Companion Guides found on the
Administrative Uniformity Committee (AUC) website at
health.state.mn.us/auc.
Claims with
Attachments
Blue Cross accepts claims with attachments electronically. The
claim must adhere to the electronic rules found in the Uniform
Companion Guides and include the appropriate populated data as
indicated in section 4.2.3.4 of the guides. The related attachment
should be faxed to Blue Cross at 1-800-793-6928 or mailed to:
Blue Cross and Blue Shield of Minnesota
P.O. Box 64338
St. Paul, MN 55164-0338
The attachment cover sheet found on the AUC website must be
used as the first page on each claim attachment. Instructions for
completing the attachment cover sheet are also available on the
AUC website.
Blue Cross has compiled a list of questions and answers in
response to provider inquiries regarding sending attachments on
electronic claim transactions.
Questions and Answers
1. My clinic has a policy of covering all documentation with
an internal cover sheet to protect PHI. Should I be covering
the attachments I am sending with this cover sheet?
No. Per the AUC Guidelines the only acceptable cover sheet
for attachments is the AUC Uniform COVER SHEET For
Health Care Claim Attachments. This form can be modified to
include a PHI message on the bottom of the page if you desire,
but is the ONLY acceptable cover sheet when sending
attachments.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (05/10/12) 8-5

Claims Filing
Claims with
Attachments
(continued)
2. Can I send appeals, adjustment requests, status checks and
general correspondence using the AUC Uniform COVER
SHEET For Health Care Claim Attachments?
No. The AUC Uniform COVER SHEET For Health Care
Claim Attachments is ONLY for use when submitting
attachments for first time claims that have been sent
electronically. It is not to be used for appeals, adjustment
requests, status checks or general correspondence. There are
separate forms and FAX numbers for these types of
correspondence. Please use the appropriate cover sheet for
each type of correspondence. Below is a list of the forms and
FAX numbers for each type of correspondence:
AUC Uniform COVER SHEET For Health Care Claim
Attachments: 1-800-793-6928 (use for attachment to
original claims only)
AUC Appeal Request Form: (651) 662-2745 (use to submit
claim appeals)
Blue Cross and Blue Shield of Minnesota Provider Claim
Adjustment/Status Check Form:
(651) 662-2745 (use to submit adjustments or to request a
status check)
For further reference on the submission of attachments,
please visit the AUC website: health.state.mn.us/auc
3. Can I change or remove the AUC Logo on the AUC
Uniform COVER SHEET For Health Care Claim
Attachments?
No. Our automated intake process looks for the AUC Logo
when preparing to scan the attachment. If the LOGO is missing
or has been changed, the automated process cannot take place.
This causes delays in the imaging of your document and
ultimately can lead to delays in the processing and payment of
your claim. This is another reason why you must not use an
internal cover sheet. You must also fax your attachment headup
or top of the page first as the recognition software only
scans the top third of the page for the LOGO.
8-6 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (05/10/12)

Claims with
Attachments
(continued)
Claims with
Coordination of
Benefits
Claims Filing
4. If I have the Other Insurance Carrier payment information
in the 837 electronic claim transaction, do I also have to
send the EOB in an attachment or notify Blue Cross that it
is in my office?
No. Per the AUC Guidelines, you should submit the Other
Insurance Carrier payment information within the 837. HIPAA
regulations forbid populating the claim record with Other
Insurance Carrier information and sending the same
information in an attachment. They further forbid sending data
in an attachment that can be codified within the claim record.
5. Can I send the attachment before I send the 837 claim
transaction?
Yes, provided you complete the PWK segment on the 837 with
the appropriate information from the AUC Uniform COVER
SHEET For Health Care Claim Attachments. The PWK
segment must include the Report Type code, Report
Transmission Code and the Transaction Control Number (the
Attachment Control Number on the AUC Uniform COVER
SHEET For Health Care Claim Attachments). Failure to
include this information on the 837 will cause delays in
processing and payment and may result in a denial of your
claim.
Blue Cross accepts electronic claims with previous payer payment
information populated per the requirements in the Minnesota
Uniform Companion Guides. For proper adjudication claims must
contain all previous payer group codes, ANSI Claim Adjustment
Reason Codes and Remittance Advice Remark Codes as you
received them from the previous payer. These claims do not
require an attachment when populated within the claim record.
Refer to the Minnesota Uniform Companion Guides, section
4.2.3.5 for more information.
Blue Cross has compiled a list of questions and answers in
response to provider inquiries regarding the electronic submission
of Coordination of Benefits information.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (05/10/12) 8-7

Claims Filing
Claims with
Coordination of
Benefits (continued)
Questions and Answers
1. I understand that there is information on the HIPAA 835
transaction that I have to include on the electronic 837
COB transaction. Can you tell me what I have to include so
I can make sure I get paid accurately?
It is important to use the Minnesota Uniform Companion
Guides along with the HIPAA Implementation Guides to
ensure the correct segments and elements are completed. The
2320, 2330A, 2330B, and the 2430 loops carry a good portion
of the COB information a payer needs to process a secondary
claim.
The HIPAA 835 transaction provides most of the necessary
information to complete the appropriate segments and
elements.
The HIPAA 835 transaction from the prior payer(s) should
provide the CAS segments (loops 2100 and/or 2110), CLP
segment (loop 2100), and the SVC segment (loop 2110), which
are used to complete the 837 COB transaction.
2. I understand the CAS segment is important for the correct
processing of my COB 837 transaction. Where do I get the
CAS segment information from?
Again, the CAS segment information on the 837 COB
transactions should come directly from the prior payer(s)
HIPAA 835 or Remittance Advice/Explanation of Benefits.
This information must never be altered or combined in any
manner.
3. Do I need to do any combining of Claim Adjustment
Reason Codes or change them to specific codes a
Supplemental Insurer might want?
No, when completing the COB information on the 837 use the
information as it was provided on the prior payer(s) HIPAA
835 or Remittance Advice/Explanation of Benefits. Never
change or alter any of the prior payer(s) payment information
including the Claim Adjustment Reason Codes (CARC), Claim
Adjustment Group Codes, and Remittance Advice Remark
Codes. Changing codes is a violation of HIPAA and could
result in payment errors or processing delays. Per the HIPAA
Implementation Guide, “Codes and associated amounts should
come from 835s (Remittance Advice) received on the claim.”
Payers utilize the codes to adjudicate based on the information
sent.
8-8 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (05/10/12)

Claims with
Coordination of
Benefits (continued)
Claims Filing
4. I know there are Medicare primary claims that should
have crossed over and Medicare has had some problems
lately with not being able to cross claims over to
supplemental payers. Should I send all my Medicare
Primary COB claims just in case?
No, “automatic” rebilling often results in duplicate claims,
increases administrative costs, and delays processing. Please
refer to Medicare Primary COB Claim section later in this
chapter.
If your claim is not showing as crossed over on provider web
self-service after 30 days from the date you received your
Medicare payment, then you may submit the claim
electronically populating the claim record with the COB
information exactly as you received it on your Medicare ERA.
5. I have situations where my Medicare primary claims have
been adjusted and Medicare is now paying on claims they
have denied. How do I send these COB claims to my
supplemental insurer?
These claims are COB adjustments to the original claim and
should crossover to us directly from Medicare. Again, please
refer to Medicare Primary COB Claim section later in this
chapter.
If the adjustment did not crossover as it should have within 30
days after you received the updated Medicare ERA, submit an
adjustment/replacement claim.
6. I have a claim where Medicare paid first. They have now
decided to pay one of the services on my three line claim.
Should I just send in the COB claim for that one line for
Blue Cross to pay the coinsurance and deductible?
No, never send a partial claim. This would be a violation of the
rules in the Minnesota Uniform Companion Guides. Again,
this could result in duplicate claims, increased administrative
costs, and processing delays. If the prior payer has made a
change to the original or prior claim processing outcome, the
original or prior claim must be adjusted to ensure the
secondary payment is correct. A “partial” claim should never
be sent regardless of whether it is an original or adjustment. As
noted in response to question #3 above, if the prior payer has
adjudicated a claim with three services lines, all three service
lines should be sent to the secondary payer. Never alter the
charges and critical claim information when sending it to a
secondary / tertiary payer for payment consideration.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (05/10/12) 8-9

Claims Filing
Claims with
Coordination of
Benefits (continued)
Medicare/Uniform
Companion Guide
Coding Alignment
7. I have talked with other providers and they tell me that a
COB claim must balance. What must balance?
The claim paid amounts must be equal to or greater than the
line level paid amounts. The CAS segments must always
reflect exactly what the prior payer has indicated on HIPAA
835 transaction or Remittance Advice/Explanation of Benefits.
Do not add or combine the CAS information. Typically, the
professional claim allowed and paid amounts should not be
greater than the billed amounts. More information regarding
balancing is available in the HIPAA Implementation Guides
available for purchase from Washington Publishing
(wpc-edi.com).
8. When the prior payer is Medicare how do I list them as the
primary payer? Do I list them by the Medicare Office,
CMS, Federal Medicare, the name of the Medicare
contractor, etc?
When Medicare is the prior payer, we suggest listing the prior
payer as “Medicare.”
9. I am sending COB in the 837 transaction and also sending
the EOB as an attachment with the report type code EB
and report transmission code AA. This is to make sure that
you get the COB information.
In these situations, the Report of Transmission (PWK02) is AA
indicating the EOB is available upon request at the provider
office. The HIPAA 837 Implementation Guides, Report of
Transmission (PWK Segment), states “The PWK segment is
required if there is paper documentation supporting this claim.
The PWK segment should not be used if the information
related to the claim is being sent within the 837 ST-SE
envelope.” Therefore sending the information within the
transaction and also sending the PWK would be non-compliant
and result in a rejection.
Blue Cross has made several system modifications to accept
claims coded using the rules indicated by either Medicare or the
Minnesota Uniform Companion Guides, Appendix A. Some billed
charges still may not be covered due to member benefits or Blue
Cross payment policy. Code your claims to meet the specifications
set forth in the Minnesota Uniform Companion Guides.
8-10 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (05/10/12)

Claims Filing
Questions Questions regarding the content of the PA02 electronic reports or
Availity payer reports should be directed to provider services at
(651) 662-5200 or 1-800-262-0820. Questions regarding the payer
electronic reports not being received should be directed to your
clearinghouse. If your clearinghouse is Availity, please refer to
their website at availity.com.
For questions regarding the attachment requirements, attachment
cover sheet and related instructions, Coordination of Benefits or
coding requirements, refer to the AUC website at
health.state.mn.us/auc.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (05/10/12) 8-11

Claims Filing
1500 HICF Form
Professional Claim
Submission
The paper 1500 Health Insurance Claim Form (HICF) (also
referred to as the CMS 1500) is accepted only from out-of-state
nonparticipating providers per Minnesota Statute 62J.536 and the
Blue Cross provider contracts.
The electronic transaction 837P is the only accepted claim
submission format for professional claims.
1500 HICF Manual The National Uniform Claim Committee (NUCC) has a reference
instruction manual detailing how to complete the 1500 HICF form.
The purpose of this manual is to help standardize nationally the
manner in which the form is being completed. A copy of the
instruction manual is available on the NUCC website -
www.nucc.org.
About the NUCC The National Uniform Claim Committee is a voluntary
organization whose members include representatives from major
provider, payer, health researchers, and other organizations
representing billing professionals, and electronic standard
developers.
The NUCC maintains the uniform data set known as the National
Uniform Claim Committee Data Set designed for the noninstitutional
claims. The NUCC is also a signatory to a
Memorandum of Understanding with five other organizations
designated by the U.S. Department of Health and Human Services
to collectively serve as the Designated Standard Maintenance
Organizations (DSMO) to the HIPAA Transaction Standard
Implementation Guides.
8-12 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (05/10/12)

UB-04 (CMS 1450) Form
Institutional Claim
Submission
Claims Filing
The paper UB-04 (also referred to as the CMS-1450) is accepted
only from out-of-state nonparticipating providers per Minnesota
Statute 62J.536 and the Blue Cross provider contracts.
The electronic transaction 837I is the only accepted claim
submission format for institutional claims.
UB-04 Manual The National Uniform Billing Committee (NUBC) publishes a
manual containing the claim data specifications that are submitted
on the 837I or UB-04 claim format and guidelines on completion
of the UB-04 form.
About the NUBC Established in 1975, the NUBC is the official data content body
responsible for maintaining the data set for institutional health care
providers. Representation includes provider, payer, electronic
standards development organizations, public health data standards
organizations, and others. The NUBC is also one of six Designated
Standard Maintenance Organizations (DSMO) responsible for the
maintenance and development of HIPAA administrative
simplification transaction standards. (Note: Also see
http://www.nubc.org/INFORMATION_ON_UB-04.pdf)
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (05/10/12) 8-13

Claims Filing
Ordering Forms and Manuals
HCPCS, CPT and
ICD-9-CM Manuals
HIPAA Implementation
Guides
Minnesota Uniform
Companion Guides
1500 HICF (CMS-1500)
UB-04 (CMS-1450)
Forms
HCPCS, CPT and ICD-9-CM manuals can be purchased from
major bookstores or publishers, such as the American Medical
Association.
To order national Electronic Data Interchange Transaction Set
Implementation guides on paper or electronic versions, contact
Washington Publishing Company.
1-800-972-4334
Or visit their website at:
www.wpc-edi.com
Minnesota Uniform Companion Guides containing instructions for
electronic transactions are available free of charge on the AUC
website under “Guides” at:
health.state.mn.us/auc/
To order 1500 HICF and UB-04 forms contact:
U.S. Government Printing Office
(202) 512-0455 or visit the website at:
cms.hhs.gov/CMSForms/
You may also contact form vendors or publishers, such as the
American Medical Association or the American Hospital
Association.
UB-04 Manual To order the UB-04 Manual contact:
National Uniform Billing Committee (NUBC) at
nubc.org/become.html for more information and an order form,
or call the American Hospital Association at (312) 422-3390 for
questions.
1500 HICF Manual The National Uniform Claim Committee 1500 Health Insurance
Claim Form Reference Instruction Manual is available at
nucc.org/.
8-14 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (05/10/12)

Professional/837P Billing
Claims Filing
Zero Billed Charges Blue Cross will allow zero-billing or no charge submission lines
on claims.
Linking and
Sequencing
It is essential to communicate the primary diagnosis for the service
performed, especially if more than one diagnosis is related to a line
item. Adjudication is based on the first linked diagnosis.
Linking/sequencing rules:
Sequence numbers relate to the ICD-9-CM diagnosis codes as
1, 2, 3 and 4.
The primary diagnosis is listed first in the sequence if more
than one diagnosis is related.
Place of Service Codes Only nationally assigned place of service codes are accepted.
These codes are available at the following web address:
http://www.cms.hhs.gov/PlaceofServiceCodes/Downloads/place
ofservice.pdf
Site of Service Blue Cross is specifying, for clarity, the difference between a
facility and a non-facility with respect to the place of service
where a service was rendered. For billing purposes, professional
(837P) billers should use an appropriate place of service code to
indicate where services were rendered. Examples of facilities
include hospitals and ambulatory surgery centers. Examples of
non-facilities include a provider's office and all places not listed
below.
The following is a current comprehensive list of facilities, as
defined by Blue Cross:
Place of Service Code Place of Service Name
21 Inpatient hospital
22 Outpatient hospital
23 Emergency room - hospital
24 Ambulatory surgical center
26 Military treatment facility
31 Skilled nursing facility
34 Hospice
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (05/10/12) 8-15

Claims Filing
Site of Service
(continued)
Freestanding
Ambulatory Surgery
Center Billing
Place of Service Code Place of Service Name
41 Ambulance - land
42 Ambulance - air & water
51 Inpatient psychiatric facility
52 Psychiatric facility - partial
53 Community mental health
center
56 Psychiatric residential treatment
center
In order to streamline our administrative processes and comply
with regulatory requirements, Blue Cross contracts with
Freestanding Ambulatory Surgery Centers as professional
submitters and requires the following guidelines and provisions:
Use of Professional Claims Submission Formats —
Freestanding Ambulatory Surgery Center providers submit
claims utilizing a HIPAA 837P claims transaction, in
compliance with Minnesota Statute 62J.52. Use national place
of service code 24.
Fee Schedule Based Payment Methodology – APC weights
were used to create fee schedule allowances (Allowance=APC
weight x conversion factor) for each procedure code, as
appropriate.
Recognition of Multiple Surgeries and Bilateral
Procedures – For multiple surgeries, the procedure with the
highest allowed amount is reimbursed at 100% of the allowed
amount. Subsequent services are reimbursed at 50% of the
allowed amount. Bilateral surgeries are billed on one line with
the -50 modifier and are reimbursed at 150% of the allowed
amount.
Adjudication of Services at the Claim Line Level – Payment
is calculated at the lesser of 100% of the provider’s regular
billed charge or the Blue Cross fee schedule allowance,
implemented at a claim line/service level.
8-16 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (05/10/12)

Freestanding
Ambulatory Surgery
Center Billing
(continued)
K3 Segment Usage
Instructions for
Condition Codes
Claims Filing
Payment of Individual Procedures – APC methodology
determines which services are included/excluded from separate
reimbursement, including implants/devices and tissue. Services
excluded from separate reimbursement are listed on the
provider fee schedule with a zero allowance. Professional
services, including anesthesia, should not be billed under this
agreement. Individual provider NPI numbers are not required.
Corneal tissue – Claims that contain corneal tissue charges
must be submitted with an attachment containing a copy of the
invoice for that corneal tissue.
99199 – The code 99199 (unlisted special service, procedure or
report) will not be considered for separate reimbursement when
submitted by an ASC. 99199 will be denied as provider
liability. No additional reimbursement will be considered on
appeal.
L8699 - Code L8699 (prosthetic implant, not otherwise
specified) will not be considered for separate reimbursement
when submitted by an ASC as it is not part of the ASC
contracted fee schedule. L8699 will be denied as provider
liability. No additional reimbursement will be considered on
appeal.
Condition Code
The NUBC has added condition codes to their code set to identify
situations where workers’ compensation requires duplicate or
appeal submissions. The 837P format does not include a
standardized way of reporting condition codes. To report
applicable condition codes on a professional claim, the K3
segment should be used.
BG is the qualifier to indicate this value and should be followed by
the appropriate condition code (refer to the NUBC Guide and Code
Set available from the National Uniform Billing Committee at
nubc.org.
Report at 2300 loop only.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (05/10/12) 8-17

Claims Filing
Institution (837I) /Facility Billing
Claim Format
Regulations
HIPAA Administrative Simplification code and transaction
regulations dictate the standard claim format and codes for
electronically submitted claims. Institutional claims are billed on
the 837I electronic format. The paper equivalent is the UB-04
claim form.
Blue Cross considers the following providers as institutional and
as such, should bill on the institutional claim format (837I).
Category Definition
Home health
agency
HHA is a public agency or private organization
that is primarily engaged in providing skilled
nursing services and other therapeutic services,
such as physical therapy, occupational therapy,
medical social services and home health aide
services. Home health agencies can be
freestanding or hospital attached. Care is rendered
in the home and is in lieu of hospital confinement.
Hospice Hospice programs provide health care for
terminally ill patients. Care may be done in the
patient’s home, at special hospice units, or a
separate hospice care facility.
Hospital An institution that provides medical, diagnostic
and surgical care. Services can be rendered on an
inpatient or outpatient basis.
Nonresidential
treatment
center
This type of institution is the same as a residential
primary treatment center with the exception that
services are rendered on an outpatient basis only.
Nursing home A Skilled Nursing Facility provides skilled
nursing care and related services for patients who
require medical or nursing care; or rehabilitation
services for injured, disabled or sick people.
8-18 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (05/10/12)

Claim Format
Regulations
(continued)
Procedure Code
Regulations
Category Definition
Psychiatric
hospital
Residential
primary
treatment
center
(IP chem dep)
Claims Filing
A psychiatric hospital provides care to
emotionally ill patients. These facilities must be
licensed by the state in which they are located.
Residential treatment programs for chemical
dependency are planned and purposeful sets of
conditions and events for the care of inebriated
and drug dependent persons which provides care
and treatment for five or more inebriate or drug
dependent persons on a 24 hour basis. Excluded
for this definition are receiving (detoxification)
centers.
The medical procedure code set for inpatient services is ICD-9-
CM procedure codes. Procedure information will be reported on
outpatient claims using HCPCS codes.
Revenue Codes (FL 42) A revenue code identifies a specific accommodation and/or
ancillary service or billing calculation. A revenue code is four
characters. The first digit is usually a 0 (zero); however, there are
codes that begin with numbers other than 0 (100X, 210X, 310X). It
is important to report all four digits.
HCPCS/
Accommodation
Rates/HIPPS Rate
Codes (FL 44)
For inpatient bills, the accommodation rate relating to the room
and board revenue code is entered.
For outpatient bills, report the HCPCS code, if applicable, to
indicate the specific outpatient service. Some HCPCS codes or
billing situations may require submission of modifiers. Modifiers
are reported following the HCPCS code. Blue Cross accepts all
valid modifiers. Although we currently do not automatically
adjudicate the claim/service based on modifiers, it is still important
to submit all modifiers, if applicable.
Duplicate Billing Blue Cross will only reimburse the professional or clinic services
when a patient is seen in a clinic setting (POS 11). Facilities that
have clinics physically located onsite or next to a hospital
frequently bill an additional claim either electronically or on an
837I with a place of service 22 for the same services that the
physician is billing. In some cases, facilities submit revenue code
0361. We consider this practice duplicate billing. Facility overhead
is included in the professional reimbursement weighting and
conversion factor; therefore, complete and final reimbursement
will be made on the professional claim only.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (05/10/12) 8-19

Claims Filing
Treatment Room Blue Cross considers specialty services of a treatment room as an
overhead expense reimbursed as part of the physician’s
professional fee. Therefore, billing facility fees through the 0760,
0761 or 0769 codes duplicates the physician’s professional claim
(837P) and will deny as provider liability.
If Medicare if primary, and Blue Cross or Blue Plus is secondary,
we will accept the 0760, 0761 or 0769 revenue codes, and process
according to Medicare’s guidelines.
Observation Room Observation Care, billed under revenue code 0762, is allowed for
admits of fewer than 24 hours. A claim for observation services
over 24 hours will be processed as an inpatient claim.
Clinic Charges Clinic charges, billed under revenue code 051X, are considered an
overhead expense reimbursed as part of the physician’s
professional fee. Therefore, billing facility fees through the 0510-
0519 revenue codes duplicates the physician’s professional claim
and will deny as provider liability.
Transfer Case A transfer case is defined as a patient who is being discharged
from one facility to another.
Patient status codes are a required field on the institutional claim
(837I). This code indicates the patient’s status as of the “Through”
date of the billing period. It is important to note that the patient
status code indicates a destination and not a level or type of care
received.
When a patient is transferred/discharged to another facility, patient
status may affect reimbursement. All patient status codes are
accepted but not all will result in a transfer case classification. The
following patient status codes are used by Blue Cross to classify a
transfer case.
Code Definition
02
05
Discharged/Transferred to a Short-Term General Hospital
for Inpatient Care
Discharged/Transferred to a Designated Cancer Center or
Children’s Hospital
Usage Note: Transfers to non-designated cancer hospitals
should use Code 02. A list of (National Cancer Institute)
Designated Cancer Centers can be found at
www3.cancer.gov/cancercenters/centerslist.html
8-20 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (05/10/12)

Transfer Case
(continued)
Code Definition
Claims Filing
43 Discharged/Transferred to a Federal Health Care Facility
65
70
Discharged/Transferred to a Psychiatric Hospital or
Psychiatric Distinct Part Unit of a Hospital
Discharged/Transferred to Another Type of Health Care
Institution not Defined Elsewhere in this Code List
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (05/10/12) 8-21

Claims Filing
Single facility claim
submission
Blue Cross generally will not accept additional facility claims for
the same encounter, normally referred to as late charges. To assure
correct adjudication and payment of services, Blue Cross requires
all related services to be submitted on the same single facility
claim (837I).
Late charges – A late charge refers to those claims that the
provider is submitting after an admit-through-discharge claim
or for the same encounter. A late charge contains charges
omitted from the original bill and the charges are submitted as
an add-on to the original bill. A late charge bill is not allowed
according to the Minnesota Uniform Companion Guide for
Institutional Claims. It is also not allowed for paper claim
submission.
Encounter – Encounter means an instance of direct
provider/practitioner to patient interaction, in an outpatient
facility setting, for the purpose of diagnosing, evaluating or
treating the patient’s condition, and during which eligible
health services are rendered to the member.
Exceptions – Exceptions that may justify separate claims may
include:
Separate ER visits – separate emergency room visits on
the same date of service
Ambulance services
Late charges – unrelated diagnosis: Outpatient charges
with same date of service submitted as separate claims with
unrelated diagnosis will no longer be denied as late
charges. The duplicate review process has been updated
with the following examples of exceptions to late charge
(replacement claim) processing. Use these as a guide to
determine if the claim situation meets the criteria as
‘unrelated’.
1. Patient has a mammogram, subsequently, in another
department, the patient received chemotherapy (for
other than breast cancer).
2. Patient receives therapy, subsequently, in another
department, the patient has an electrocardiogram.
3. Patient is seen for a radiation therapy, subsequently,
in another department, the patient is seen for routine
screening.
4. Patient receives therapy and subsequently visits the
ER for a unrelated condition (e.g., injury or acute
illness unrelated to the therapy received)
8-22 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (05/10/12)

Claims Filing
Zero Billed Charges Blue Cross will allow zero-billing or no charge submission lines
on claims.
Lactation Education For billing purposes, lactation services are considered to be part of
the mother’s charges and should not be billed on the newborn’s
claim.
0636 Drugs Requiring
Prior Auth
Present on Admission
(POA)
Submit all claims for lactation education on the 837I claim form
using revenue code 0942. These charges must be submitted on the
mother’s original maternity/delivery claim and require a narrative
description.
Claims for lactation services submitted under the infant’s name or
number will be rejected.
If lactation education is necessary after discharge, it can be billed
as part of the post-partum visit under the mother’s identification
number.
Revenue code 0636, by definition, is for drugs requiring detailed
coding. A HCPCS code must always be submitted with 0636.
However, some drugs that may be submitted under this revenue
code also require prior authorization. The following are examples
that require prior authorization:
IVIG
Aminolevulinic Acid
Factor products
Blue Cross requires the present on admission (POA) indicator on
all claims (Medicare and commercial, including the
MedicareBlue SM PPO [Regional PPO] claims, Platinum Blue SM
[Cost], SecureBlue SM [HMO SNP], CareBlue SM [HMO SNP] and
Blue Advantage) for inpatient admissions to general acute care
hospitals.
General Reporting Requirements
The POA indicator is required for all claims involving
Medicare and commercial inpatient admissions to general
acute care hospitals.
The POA indicator is assigned to principal and secondary
diagnoses.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (05/10/12) 8-23

Claims Filing
Present on Admission
(POA) (continued)
Present on admission is defined as present at the time the order
for inpatient admission occurs. Conditions that develop during
an outpatient encounter while in the emergency room, under
observation or during outpatient surgery are also considered as
present on admission.
If the condition would not be coded and reported based on
Uniform Hospital Discharge Data Set definitions and current
coding guidelines, then the POA would not be reported.
The POA indicator is not required for the external cause of
injury code unless it is being reported as an “other diagnosis.”
Critical Access Hospitals, Maryland waiver hospitals, longterm
care hospitals (LTCH), cancer hospitals and children’s
inpatient facilities are exempt from this requirement.
Form Completion Instructions
For electronic claims using the 837I, refer to the Minnesota
Uniform Companion Guide for the Institutional Electronic Health
Care Claim Transaction (ANSI ASC X12 837I). Information on
submission of the POA indicator is found in appendix D of the
guide. The guide can be accessed at the following link:
health.state.mn.us/auc/mn837i.pdf. POA indicators should only
be submitted along with correlating DX codes.
On UB-04 (CMS-1450) paper claims, the POA indicator is the
eighth digit of Form Locator (FL) 67, Principal Diagnosis and the
eighth digit of each of the Other Diagnosis fields FL 67 A-Q. One
POA indicator is submitted per diagnosis. POA indicators should
only be submitted along with correlating diagnosis codes.
Use the POA indicators as you would normally submit to
Medicare. For more information, refer to
cms.hhs.gov/HospitalAcqCond
8-24 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (05/10/12)

Claims Filing
Claims Filing
Timely Filing Most member contracts contain a time limit for claims submittal.
The limit is usually six (6) months after the date of service, with a
few exceptions. Timely filing for Federal Employee Program
(FEP) members can be found in Chapter 5- ID Cards/Coverage
Options. Participating providers are required to submit original
claims within six (6) months of the date of service. The provider is
liable for claims not submitted within the timely filing limit.
Claims Crossover for
Medicare and Medicare
Supplement
For medical care that involves follow-up, such as surgery and
routine postoperative care, it is most efficient to bill us after all
services have been completed, as long as it is within the time limit.
Replacement Claims
Blue Cross’ requirements for timely filing of replacement claims is
six calendar months from the process date of the predecessor claim
There is no timely filing limit on cancel claims (claim frequency
code of 8).
Provider-Submitted Appeals
Blue Cross’ requirements for timely filing of provider-submitted
appeals is 90 days from the process date of the claim
The claims crossover system reduces your paperwork by using the
Medicare claim form to process both Medicare and Medicare
Supplement benefits. Through the crossover, Medicare generates a
second claim automatically for members who have secondary or
supplemental benefits with us. Providers have only one claim form
to submit—the 837P for Medicare Part B or the 837I for Medicare
Part A.
While Blue Cross can only accept changes from the member, we
encourage providers who are aware of Health Insurance Claim
Number (HICN) changes to assist their patients in communicating
this information to us.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (05/10/12) 8-25

Claims Filing
Medicare Crossover Blue Cross provides COBC a weekly eligibility file of all Blue
Cross members enrolled for coverage under the Medicare program.
When Medicare processes a claim, the Medicare patient’s HICN
will be compared to the HICNs on the eligibility file sent by us. If
found, the date of service on the Medicare claim will be compared
to the Blue Cross coverage effective and cancel dates. If the
claim’s date of service falls within those dates, the claim will be
crossed over to us electronically.
837I Crossover
Information
837P Crossover
Information
The current message indicating the claim was sent to Blue Cross
will continue to be displayed on the patient’s Medicare Summary
Notice (MSN) or on the Explanation of Medicare Benefits
(EOMB). Medicare will indicate on the provider’s Remittance
Advice (RA) if the claim was sent to the supplemental insurer. On
the Intermediary RA, claim status codes of 19, 20, or 21 indicate
that the claim was crossed over. If the HICN is not found on the
Blue Cross eligibility file, or if the date of service on the claim is
outside the given Blue Cross coverage effective and cancel dates,
the claim will not be forwarded to us electronically.
A note associated with the ANSI remark code indicates which
payer will receive the claim information. Providers will continue to
see MA18 and the name of the payer on the Medicare RA when
the payment information is forwarded to a single payer. However,
code N89 will be used when the payment information is forwarded
to multiple payers; only one of those payers will be named on the
RA even though the payment information is forwarded to multiple
payers.
Paper claims submitted to Blue Cross with the Medicare RA
attached and the N89 remark code stating the payment information
was forwarded to Blue Cross will be returned to the provider.
Adjusted Medicare B claims will not be crossed over to us.
If the claim is not forwarded, then:
The statement or code indicating the claim was forwarded to us
will not appear on the MSN, EOMB or RA.
The patient or provider must submit the electronic claim to us
populating Medicare’s payment information within the claim
record.
8-26 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (05/10/12)

Claims Filing
Duplicate Claims Duplicate billing adds millions of dollars each year to health care
administrative costs. Many providers operate under the erroneous
assumption that frequent rebilling leads to faster payment.
Unnecessary rebilling increases your overhead costs as well as
ours. Below are several ways you can help reduce duplicate claims
costs:
When you file the claim, be sure to tell your patients not to bill
on his/her own.
Eliminate ‘‘automatic’’ rebillings. Wait 30 calendar days for us
to process your claim.
Before you rebill use provider web self-service, call
BLUELINE ® , use a 276/277 transaction or call provider
services for claim status information.
Don’t submit previously billed claims with new claims “just to
be safe.” This only delays payment of all new claims.
If you receive a Medicare RA showing that the claim has
electronically been ‘‘crossed over’’ to us, do not submit the
paper RA as a claim.
If a claim has been denied, resubmitting the paper RA will only
result in a second denial. Either correct fields on the claim and
submit a replacement claim or submit an appeal as appropriate.
Submission of Claims Our goal is to pay your claims as quickly as possible. By following
the above suggestions, you can help hold down everyone’s
administrative costs.
To ensure the proper administration of benefits by Blue Cross,
providers shall submit claims to Blue Cross even when their claims
have been paid in full by other third parties such as Medicare.
When submitting claims in these cases, the provider shall populate
the previous payer’s payment information within the claim.
Providers shall submit claims to Blue Cross for all services
provided, even in cases when the provider suspects a service will
not be covered except charges identified in chapter 9, page 9-5.
This will ensure the proper administration of benefits and take
advantage of changes in coverage that may occur after the provider
checks benefits.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (05/10/12) 8-27

Claims Filing
Cancel/Void and
Replacement Claims
Minnesota statute 62J.536, requires providers to submit all claims
electronically. This requirement includes all cancel and
replacement claims as well as original submissions. Cancel claims
are claims that should not have been billed or where key claim
information such as the billing provider or patient name were
submitted incorrectly. Replacement claims are sent when data
submitted on the original claim was incorrect or incomplete.
Minnesota providers and out of state providers who participate
with Blue Cross are no longer allowed to submit adjustment
requests via paper or through provider web self-service at
providerhub.com. Providers are required to adhere to the State of
Minnesota Uniform Companion Guide requirements and the AUC
Best Practices for replacement claims. Additionally, provider
services will no longer accept requests to change data elements
within a claim as these should be sent electronically as
replacement claims. Provider services will still accept requests to
adjust claims in situations where the claim processed incorrectly
even though correct information was provided on the original
submission.
Exceptions
Exceptions to this electronic replacement claims enforcement are
as follows:
Dental formatted adjustment requests will still be accepted if
received on paper.
Pharmacy formatted adjustment requests will still be accepted
if received on paper.
Nonparticipating providers that are located in counties that
border Minnesota are exempt from the statute, therefore paper
claims will still be accepted from these providers.
Adjustment Requests received from the Veterans
Administration (VA) and Indian Health Services.
Additional Information
If you are unable to send electronic replacement and/or cancel
claims, Blue Cross has secured the services of Availity to provide
a free web-based tool for provider data entry of claims. To learn
more about submitting claims using Availity’s no-cost web-based
tool, go to availity.com.
8-28 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (05/10/12)

Cancel/Void and
Replacement Claims
(continued)
Claims Filing
Blue Cross and its affiliates have completed system changes to
accept and properly adjudicate electronic cancel and replacement
claims.
Following are some of the common questions related to proper
submission requirements. Section A contains general information,
and section B is for specific handling of coordination of benefits
(COB) related scenarios.
Section A- General Information
1. What is an example of a replacement claim? I have read
the AUC description and would like some clarity on these
claims.
A replacement claim, to paraphrase the Minnesota Uniform
Companion Guides for claims, is used to completely replace a
previously submitted claim when data within the claim record
is added, changed or deleted. An example would be a
professional claim sent with all diagnosis pointers set to “1.”
On review by the provider after original payment, it is
determined the second procedure was done in reference to the
third diagnosis on the claim. A replacement claim is sent to
correct the diagnosis pointer on line 2.
See section 4.2.3.2 of the Minnesota Uniform Companion
Guides and the related AUC Replacement/Void Claims Best
Practice available on the AUC website at
health.state.mn.us/auc.
2. Can I send a replacement claim if I have the wrong
subscriber ID on the previous submission?
No. According to the AUC Replacement/Void Claims Best
Practice, “When identifying elements change, a void
submission is required to eliminate the previously submitted
claim.” Changes to identifying information related to the
billing provider, patient, payer, subscriber or statement covers
period dates, require that a cancel claim transaction be
submitted for the original claim and that a new claim with the
corrected information be submitted to the payer. These
requirements are similar to the Centers for Medicare &
Medicaid Services (CMS) requirements.
3. Can I send an attachment on a replacement claim?
Yes, if it is relevant to the changes being made on the
replacement claim or needed to support a particular coding
change. For example, the addition of a -59 modifier to indicate
that the service being billed is a distinct procedure or service
will require supporting medical documentation to be submitted
with the replacement claim.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (05/10/12) 8-29

Claims Filing
Cancel/Void and
Replacement Claims
(continued)
4. If Blue Cross denied my claim because the date of injury
was required but not submitted in the claim, can I send an
AUC Appeal Request Form to have the claim reconsidered
and list the requested date of injury in the Reason for
Appeal section?
No. You must submit a replacement claim with the corrected
data (injury date) in the 837 transaction.
5. What is an appeal?
The Minnesota Uniform Companion Guides describe an appeal
as “Provider is requesting a reconsideration of a previously
adjudicated claim but there is no additional or corrected data to
be submitted.” For example, you receive a claim denial
because we considered the procedure investigative. Your
request to reconsider must be submitted on the AUC Appeal
Request Form along with supporting documentation following
the instructions in the AUC Submission of Appeals Best
Practice. Fax the AUC Appeal Request Form and supporting
documentation to Blue Cross at (651) 662-2745.
6. What are some examples of reasons for appeals?
The following is a list of reasons to send an appeal, according
to the Minnesota Uniform Companion Guide(s) for Claims:
Timely filing denial
Payer allowance
Incorrect benefit applied
Eligibility issues
Benefit accumulation errors
Medical policy/medical necessity
7. All of the claim information was submitted correctly;
however, it appears not all claim data I sent was recognized
by the system. Is it acceptable for me to call Blue Cross to
simply have my claim adjusted using what was previously
submitted or do I need to appeal?
It is acceptable for you to request the claim be adjusted to
recognize the data within the submission through a phone call
to provider services. It would also be acceptable for you to
submit your request using the AUC Appeal Request Form.
8-30 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (05/10/12)

Cancel/Void and
Replacement Claims
(continued)
Claims Filing
8. I am sending documentation in response to a request for
additional documentation from Blue Cross. Do I need to
send a replacement claim with the attached medical
records?
If you are responding to an information request letter sent by
Blue Cross, regardless of whether you have also received a
denial on your remittance, you should submit the requested
information, along with a copy of the information request
letter. Do not send an AUC Appeal Request Form. These same
instructions are included on the letter that you receive.
9. I am sending documentation in response to a denial on my
remittance advice from Blue Cross. Do I need to send a
replacement claim with the supporting information
needed?
If you are sending the additional documentation as a result of a
denial on a remittance advice only, and not in response to an
information request letter from Blue Cross, and the claim
requires changes to claim data elements (such as date of injury,
procedure code changes, diagnosis code changes, etc.), then a
replacement claim must be sent which includes any necessary
attachments.
If you are sending the additional documentation as a result of a
denial on a remittance advice only and the claim does not
require changes to claim data elements you also may send a
replacement claim.
If you are sending additional documentation because you
believe you did not receive correct payment and this
documentation supports your position, you must send the AUC
Appeal Request Form along with the documentation to support
your request.
Section B – COB Related Scenarios
1. How do I send COB information when it was not included
with the previous submission?
Scenario 1
If you have received a HIPAA compliant remittance advice
(835), and your system has the capability to populate the
information within a secondary claim, you must submit a
replacement claim with the data appropriately entered
within the claim record.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (05/10/12) 8-31

Claims Filing
Cancel/Void and
Replacement Claims
(continued)
Scenario 2
If you have not received a HIPAA compliant remittance
advice (835) from the previous payer, you may send a
replacement claim transaction with the addition of the
PWK segment and send the paper remittance advice from
the previous payer as an attachment.
Note: All Minnesota Group Purchasers must provide a
HIPAA and State of Minnesota compliant
remittance advice, and providers are required by the
Minnesota Uniform Companion Guides (section
4.2.3.5) to submit the previous payment information
electronically using the proper fields within the
claim transactions.
Additional Information
For additional information on these types of claims, please refer to
the Minnesota Uniform Companion Guides and related Best
Practice documentation on the AUC website at
health.state.mn.us/auc/guides.htm.
8-32 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (05/10/12)

Release of Medical
Records
Provider Assistance
Requested
Medical Records
Management Process
Improvement
Claims Filing
The Minnesota Statute that states “consent for the release of
medical records are valid for only one year,” also provides that
consents to release medical records to insurers for purposes of
claims payment do not expire after one year. Since there are
circumstances where such consents are only valid for one year,
providers may wish to update their records on an annual basis.
Providers are reminded that:
Provider contracts state “The provider shall promptly furnish
any additional information that Blue Cross or the Plan sponsor
shall reasonably request as necessary to respond to claims.”
HIPAA considers release of such records as required for
“business operations.”
ARIs are required under Minnesota law.
Providers should gather information from patients on an annual
basis to facilitate timely processing of patient claims.
Blue Cross is improving its medical records management process
to better serve you.
Reduced requests - Changes to the Blue Plan internal medical
records procedures will eliminate unnecessary medical record
requests and expedite claims processing for members from
other Blue Plans.
Clearer instructions - A form will accompany all medical
record requests to facilitate claims processing. The form should
be returned with the requested records.
Verify Member Identity Blue Cross has received a number of calls from our members who
have stated that they did not receive certain services that were
billed under their subscriber identification number.
Upon comparing consent for treatment forms with signatures on
file it appears that such services were provided to an imposter.
In order to prevent this occurrence, providers should take
appropriate steps to verify a member’s identity, such as viewing a
government issued identification card and a Blue Cross member
ID card at each encounter.
If you suspect fraudulent use of a member ID card, please call our
fraud hotline at (651) 662-8363. You may remain anonymous.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (05/10/12) 8-33

Claims Filing
Verifying Patient
Eligibility
Minnesota Statute 62J.536 requires health care providers and
group purchasers (payers, plans) to exchange eligibility
information electronically using a standard format. The intent of
the law is to reduce costs, simplify and speed up health care
transactions, and give providers and health plans one set of rules to
follow for electronic transactions. This statute applies to all health
care providers that request benefit or eligibility information
regardless of participating status.
Rules for Checking Eligibility and Benefits
According to the Minnesota Department of Health, the compliant
modes for initial eligibility inquiries and responses are either via
provider web self-service (PWSS) or submission of the Eligibility
Inquiry and Response Electronic Transaction (ANSI ASC X12
270/271). Utilization of the Integrated Voice Response system
(IVR) is not considered compliant for this initial exchange. If, after
an initial compliant exchange (via web or EDI), additional
information or review is needed, other modes that are available
may be used, including IVR or a phone call to a service
representative.
The AUC has published a best practice related to checking
eligibility and benefits for patients. The best practice covers 4
major areas:
When and how to verify
Preferred methods of eligibility inquiry
Sharing eligibility information
Data elements that should be used to update information
systems
The recommendation of the AUC is that eligibility be checked
for each patient once per calendar month since most eligibility
changes occur at the beginning of a month. Please refer to the
best practice at the following link for other helpful tips.
www.health.state.mn.us/auc/bstprac01.pdf
Questions?
If you want to register to receive the electronic eligibility
(270/271) transaction, contact Availity at availity.com.
You can also use the provider web self-service site to check
eligibility and benefits. To apply, go to the Welcome page on
www.providerhub.com. Click on the link “Want access to this
online service for your office?”
8-34 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (05/10/12)

Basic Character Set
Values in the Electronic
Transaction
Claims Filing
The AUC has published a best practice regarding utilization of the
basic character set values within the transaction data.
The basic character set includes some punctuation characters and
spaces. These values when used unnecessarily can cause issues
with matching to the payers’ enrollment for the provider or the
member; or may cause the data to be incorrectly
extracted/interpreted within the payers’ applications.
If any of the punctuation characters within the basic character set
are used as delimiters then they cannot be used in the transmitted
data within a data element.
Punctuation and spaces should only be utilized within the elements
when they add value to the data. They should not be used when
their usage is not essential to the interpretation of the data content.
Basic character set: uppercase letters (A-Z), numeric digits (0-9),
space ( ), exclamation point (!), double quote (“), single quote (‘),
ampersand (&), right parenthesis, left parenthesis, asterisk (*),
period (.), plus sign (+), comma (,), hyphen (-), forward slash (/),
colon (:), semicolon (;), question mark (?), and equals sign (=).
Even though the “@” character is in the extended character set it is
allowed for e-mail addresses within the PER segment. This
character must not be used as a delimiter.
Examples to illustrate best practice:
Description Incorrect Examples Correct Example
Name Titles (no
period should be
used).
Address – no
periods should be
used as part of the
address.
Commas and
periods should be
used at the end of a
sentence in a text
field to separate
from another
sentence within the
text field.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (05/10/12) 8-35
JR.
MR.
PhD.
M.D.
P.O.
AVE.
A PERIOD
WITHIN A
SENTENCE MAY
HAVE VALUE
DESCRIPTION OF
SERVICE IS ABC
JR
MR
PHD
MD
PO
AVE
A PERIOD
WITHIN A
SENTENCE MAY
HAVE VALUE.
DESCRIPTION OF
SERVICE IS ABC.

Claims Filing
Basic Character Set
Values in the Electronic
Transaction
(continued)
Claim Service Dates
Restricted to Same
Calendar Month
Description Incorrect Examples Correct Example
Hyphens and
apostrophes should
not be used within a
last name field.
Leading and trailing
spaces within fields
should not be used.
SMITH-JONES
O’BRIEN
Rendering
practitioner last
name = “_JONES”
or “JONES_”
SMITHJONES
OBRIEN
Rendering
practitioner last
name = “JONES”
The AUC has published a best practice regarding claim service
dates in the same calendar month. The purpose of this best practice
is to avoid split claims and rejections. Most eligibility changes
occur at the beginning or end of a calendar month. Some payer
systems require that claims contain only services that are
associated with a particular eligibility period. Current practice is to
split these claims at the payer site to push through systems or to
reject the claim.
On a professional claim, service date spans should only be within
the same calendar month. Multiple claims may be submitted for
different dates within the same calendar month based on the
provider’s billing practices.
On an institutional outpatient claim, statement and service date
spans should only be within the same calendar month.
Observation, extended recovery and emergency department
services beginning before and completing after midnight are
exceptions to this best practice if performed during the same visit.
Procedures beginning on one day and ending on another should be
billed together.
This best practice does not apply to an institutional inpatient claim.
Pharmaceuticals should be billed with the administration/dispensed
date rather than a span of dates.
Monthly equipment rental should be billed with the start date of
the rental period only rather than the span of days.
Equipment rented on other than monthly basis needs both from and
through dates. Units of service should be reported as one (1) per
rental period. These service date spans should only be within the
same calendar month. Example would be daily rental of
equipment.
Supplies should be billed with the purchase date rather than the
span of days.
8-36 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (05/10/12)

Claim Service Dates
Restricted to Same
Calendar Month
(continued)
Reporting MNCare and
Sales Tax
Claims Filing
Refer to Appendix A of the MN Uniform Companion Guides for
additional guidance on service date coding.
Examples to illustrate best practice:
Example 1 (equipment rental single month):
Equipment is rented for January 17 through February 16. Service
date should be reported as January 17 with no end date.
DTP*472*D8*20080117~
Example 2 (equipment rental multiple months):
Equipment is rented for March 3 through May 15. Should be
submitted as three separate claims, claim one would be reported as
March 3 with no end date; claim two would be reported as April 3
with no end date; claim three would be reported as May 3 with no
end date.
DTP*472*D8*20080303~
DTP*472*D8*20080403~
DTP*472*D8*20080503~
Instructions for MNCare Tax billing only apply if the provider
bills the group purchaser for MNCare Tax. Some providers do not
bill the group purchaser for MNCare Tax. This document DOES
NOT require them to do so but if they do identify the tax it must
be done as follows. Some group purchasers may not reimburse
MNCare Tax unless it is identified in the AMT. Sales tax
instructions for professional claims are as follows:
MNCare Tax must be reported as part of the line item charge
and reported in the corresponding AMT tax segment on the
lines.
Sales tax must be reported using HCPCS code S9999 for the
tax and must be billed on the same claim as the related taxable
service.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (05/10/12) 8-37

Claims Filing
Rural Health Clinics and Federally Qualified Health
Centers
Billing for Medicare
Primary
Billing Other Than
Medicare Primary
Rural Health Clinics (RHC) and Federally Qualified Health
Centers (FQHC) are Medicare provider designations. Medicare
requires RHCs and FQHCs to bill services in an institutional
format (837I).
Since billing as a RHC or FQHC would be secondary to Medicare,
we will only accept these clinic claims on the 837I.
The claim should be submitted following Medicare billing
requirements (e.g., TOB 071X and revenue code 0521 for a clinic
visit to a RHC).
If Medicare is not primary, services must be billed to us as a clinic,
not as a RHC/FQHC, under your Blue Cross clinic provider
number or NPI and submitted as a professional claim 837P.
8-38 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (05/10/12)

Coordination of Benefits (COB)
Claims Filing
Overview Third-party payers rely on Coordination of Benefits (COB) to
eliminate duplicate payments when a patient has more than one
coverage for health services. Please complete the information
under ‘‘other coverage’’ on claims for your Blue Cross patients.
List the names of any other carriers and the member’s ID number,
if possible. We determine which carrier is primary payer and
ensure that duplicate payments are not made for the same services.
Primacy Determination We follow the National Association of Insurance Commissioners
(NAIC) rules to identify the primary insurance carrier.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (05/10/12) 8-39

Claims Filing
Coordination of Benefits Types
There are several types of coordinating benefits that are outlined below. The only way to
determine what type of COB a member has is to contact provider services.
All seven types follow these first three steps:
1. The primary carrier pays appropriate benefits under its contract.
2. The claim is submitted to the secondary plan's carrier.
3. The secondary plan will never pay more than it would pay in the absence of coordination.
COB Type 1 and 2
(Standard Coordination)
4. The secondary plan pays
the difference between the
higher allowed amount and
what the primary plan paid.
5. The combined payment of
the primary and secondary
plans will not exceed the total
incurred expenses.
COB Type 3 (Benefits less
Other Insurance Benefits)
4. The secondary plan
processes up to the secondary
plan's allowed amount. The
secondary plan subtracts the
amount the primary plan paid
from the amount it would
have paid without
coordination.
5. If the primary plan paid less
than what the secondary plan
would have paid without
coordination, the secondary
plan pays the difference.
6. If the primary plan paid
more than what the secondary
plan would have paid without
coordination, the secondary
plan pays nothing.
(Integration)
7. The combined payment of
the primary and secondary
plans will not exceed the total
incurred expenses.
COB Type 4 (only with
Medicare)
4. The secondary plan's
allowed amount is determined
by subtracting Medicare's paid
from Medicare's allowed.
5. That amount is reduced by
any applicable deductibles
and coinsurance.
6. The combined payment of
the primary and secondary
plans will not exceed the total
incurred expenses.
8-40 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (05/10/12)

COB Type 1 and 2
(Standard Coordination)
The result:
The patient would not be
responsible for payment of a
portion of his or her eligible
medical expenses.
COB Type 3 (Benefits less
Other Insurance Benefits)
The result:
The patient is responsible for
any applicable deductible or
coinsurance amounts for
eligible medical expenses
under both plans.
COB Type 4 (only with
Medicare)
The result:
Claims Filing
The patient may be
responsible for a portion of
his or her eligible medical
expenses.
Note: When coordinating benefits with Medicare all COB Types coordinate up to Medicare's
allowed amount when the provider accepts assignment and the provider is located within
the state of Minnesota. The federal Medicare Secondary Payer (MSP) law dictates when
Medicare pays secondary.
When coordinating benefits with another commercial carrier all COB types coordinate
up to the higher allowed amount between the two plans except when integration is
involved. Integration will coordinate up to Blue Cross’ allowed amount.
It is important that all charges submitted to the primary payer be submitted to the
secondary payer, even though charges were paid in full.
Workers’
Compensation
In cases where an illness or injury is employment-related, workers’
compensation is primary. If notification is received that the
workers’ compensation carrier has denied the claim, the provider
should submit the claim to Blue Cross regardless of whether the
case is being disputed. It is also helpful to send the other carrier’s
denial statement with the claim.
No-fault Auto The No-fault Automobile Insurance Act calls for automobile
insurance coverage to be primary without regard to cause or fault
for the accident. The health insurance carrier would be the
secondary payer. If notification is received that the no-fault auto
carrier has denied the claim, the provider should submit the claim
to Blue Cross regardless of whether the case is being disputed. It is
also helpful to send the other carrier’s denial statement with the
claim.
Subrogation Subrogation literally means the substitution of one person for
another. It is the right to recover payments for a member whose
personal injuries are caused by the negligence or wrongdoing of
another. Minnesota does not have specific statutes or laws that
apply to subrogation. Some group health care coverage plans and
Blue Plus do have subrogation in their certificates or contracts. For
those groups, Blue Cross will initially pay the claim until the case
is settled.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (05/10/12) 8-41

Claims Filing
TEFRA The 1982 Tax Equity and Fiscal Responsibility Act (TEFRA)
applies to employers with 20 or more employees. Under TEFRA,
group health coverage becomes the primary payer and Medicare
the secondary payer for active employees between ages 65 and 70.
TEFRA applies to active employees from the first day of the
month of their 65th birthday to the first day of the month following
their 70th birthday.
DEFRA Effective January 1, 1985, the Deficit Reduction Act (DEFRA)
expands the TEFRA aged workers guidelines to include dependent
spouses (ages 65 to 70) of actively employed workers under 70.
COBRA On April 7, 1986, the Consolidated Omnibus Budget
Reconciliation Act (COBRA) amended the Working Aged
Provision to eliminate the age 69 limit. Medicare will no longer
become primary payer when an employed person turns age 70 or
the spouse of an employed person turns 70. The group remains
primary payer until the employee retires.
OBRA The Omnibus Budget Reconciliation Act (OBRA) of 1986
introduces the term ‘‘active individual’’ and defines it as the
employee, the employer, or individual associated with the
employer in a business or family relationship. Medicare will now
be the secondary payer for disabled Medicare beneficiaries who
elect to be covered by an employer-based group health plan, either
as current employees or family of such employees. The minimum
number of employees under this provision is set at 100. The
employer’s insurance pays primary.
8-42 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (05/10/12)

Non-Physician Health Care Practitioners
Claims Filing
Introduction Blue Cross and its affiliates will pay for reasonable and necessary
services performed by certain non-physician health care
practitioners. Eligible services are determined by the practitioner’s
scope of practice and the member’s contract.
Eligibility Criteria Below is the eligibility criteria for non-physician health care
practitioners:
Non-physician health care practitioners must meet applicable
state or federal laws or licensing standards.
When collaboration is required, non-physician health care
practitioners in independent practice must work in
collaboration with a physician licensed in the state where the
services take place.
A non-physician health care practitioner not eligible as an
independent contractor must be an employee of a physician or
limited-license practitioner (such as chiropractor or
optometrist) licensed in the state where the services took place.
The employing provider must be legally and medically
responsible for the supervised employee’s services.
Eligible non-physician health care practitioners must apply for
and meet Blue Cross credentialing criteria.
Credentialed or enrolled practitioners must use the Blue Cross
individual provider number or NPI when submitting services.
Services rendered by supervised employees who are not issued
individual provider numbers must be submitted under the
supervising physician’s provider number or NPI. The -U7
modifier should be appended to the HCPCS code to indicate a
non-physician health care practitioner rendered the service.
Services rendered must be eligible under their Blue Cross
provider and member contracts and the practitioner’s scope of
practice.
A countersignature of notes and orders by the employing or
supervising physician is required if the non-physician
practitioner’s licensure and/or scope of practice requires a
signature.
Definitions Centers for Medicare and Medicaid Services (CMS) guidelines are
the basis for the following definitions. For added clarification, we
have further defined supervision as either direct or general.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (05/10/12) 8-43

Claims Filing
Employment As defined by CMS, the non-physician performing an “incidentto”
service may be a part-time, full-time or leased employee of the
supervising physician group practice or the legal entity that
employs the supervising physician. A leased employee is a nonphysician
working under a written employee leasing agreement,
which provides that:
The non-physician, although employed by the leasing
company, provides services as the leased employee of the
physician or other entity; and
The physician or other entity has control over all actions taken
by the leased employee with regard to medical services
rendered to the same extent that the physician or other entity
would have such control if the leased employee were directly
employed by the physician or other entity.
To satisfy the employment requirement, the non-physician must be
considered an employee of the supervising physician or other
entity under the common law test of an employer/employee
relationship.
Services provided by auxiliary personnel not employed by the
physician, physician group practice, or other legal entity are not
covered as incident to a physician’s service.
Incident To “Incident to” physician’s professional services means that the
services or supplies are furnished as an integral, although
incidental, part of the physician’s personal professional services in
the course of diagnosis or treatment or an injury or illness.
The practitioner’s service must be furnished as an integral part
of the physician’s personal professional service in the course of
diagnosis or treatment of an illness or injury.
An employee of the physician must render service under the
physician’s direct supervision.
The physician must perform the initial and subsequent service
with a frequency that reflects his/her active participation in
managing the course of treatment.
Practitioners who are issued individual provider numbers are
considered incident to the physician when performing services
within the same encounter on the same day as the physician.
Incident to services are applicable in the office place of service
only.
8-44 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (05/10/12)

Claims Filing
Direct Supervision The physician must be present in the office suite and immediately
available to assist and direct throughout the performance of the
service. Direct personal supervision does not mean that the
physician must be present in the same room with the non-physician
practitioner. A physician cannot provide direct or personal
supervision via telemedicine. Direct supervision is only applicable
in the office place of service.
General Supervision General supervision refers to services furnished under the
physician’s overall direction and supervision. The physician does
not have to be physically present in the same office suite. He or
she may provide general supervision by periodic review of the
non-physician’s practice and availability either in person or
through electronic communications (telemedicine, telephone, etc.).
Collaboration/
Independent Practice
Chiropractic Doctors
and Multidisciplinary
Clinics
Certain practitioners are qualified to set up their own practice.
Although these practitioners work independently and do not
require physician supervision, they must work with or collaborate
with a physician. For example, a physical therapist may perform
therapy independently; however, the patient’s physician makes the
initial determination that the patient requires or will benefit from
physical therapy. The physical therapist works in collaboration
with the physician.
Chiropractic doctors must maintain separate provider contracts and
provider numbers when practicing in a multidisciplinary clinic
setting with medical doctors. Blue Cross does not allow
chiropractors to bill services as “incident to” a physician’s
services. Services performed by a chiropractor must bill under the
chiropractor’s own provider number.
The assignment of a chiropractic provider number is fundamental
to the appropriate processing of our member and provider
contracts. It allows Blue Cross to identify the specialty of the
individual providing the services. This is especially important to
enable Blue Cross to correctly administer those contracts that have
visit limitations, exclusions and other benefit variances.
A multidisciplinary clinic with medical and chiropractic doctors
must adhere to this requirement that independently licensed
chiropractors must maintain separate provider contracts with Blue
Cross and bill appropriately. There are no exceptions to this policy.
Any deviation from this billing requirement is a violation of the
Blue Cross participating agreement.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (05/10/12) 8-45

Claims Filing
Surgical Technicians Surgical technicians are considered to be hospital-based
practitioners and as such cannot have an independent relationship
with Blue Cross nor can their services be billed under a
supervising physician’s individual provider number. Surgical
technicians are members of the operating team that prepare the
patient and the operating room for surgery, transport patients,
observe vital signs and check charts during surgery.
Mid-level Practitioners Blue Cross defines mid-level practitioners based on practitioner
specialties. The practitioner's specialty is established based on their
current state license and is appropriately determined during the
credentialing process.
The following is a comprehensive current list of mid-level
practitioners:
Adult nurse practitioner
Certified nurse midwife
Clinical nurse specialist
Family nurse practitioner
Gerontological nurse practitioner
Neonatal nurse
OB/GYN nurse practitioner
Optician
Pediatric nurse practitioner
Physician assistant
Public health agency/nurse
Registered nurse first assistant
8-46 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (05/10/12)

Chapter 9
Reimbursement / Reconciliation
Table of Contents
Reimbursement .......................................................................................................................... 9-2
Payment Methodology........................................................................................................... 9-2
Direct Payment.......................................................................................................................9-2
Electronic Funds Transfer......................................................................................................9-2
MNCare Tax ..........................................................................................................................9-3
Inpatient Claims Paid at DRG Rates...................................................................................... 9-3
Complication and Co-morbidity Defined .............................................................................. 9-4
Serious Preventable Medical Errors....................................................................................... 9-5
Remittance Advice ..................................................................................................................... 9-6
Introduction............................................................................................................................9-6
Sample PDF Remittance Advice............................................................................................9-6
2006 Remittance Advice Change...........................................................................................9-6
ANSI Codes ...........................................................................................................................9-6
Questions and Answers.......................................................................................................... 9-7
Remit Balancing Tips ..........................................................................................................9-11
Accounts Receivable Recoupment Report............................................................................. 9-12
Introduction..........................................................................................................................9-12
Accounts Receivable Recoupment Report...........................................................................9-13
Field Descriptions ................................................................................................................ 9-14
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (11/02/11) 9-1

Reimbursement / Reconciliation
Reimbursement
Payment Methodology Please refer to your provider contract for professional provider
payment methodology details.
Direct Payment Because you are a participating provider, we send claims payments
directly to you. Payments are sent weekly.
Effective December 15, 2009, Minnesota Statute 62J.536 requires
all health care providers to accept from group purchasers the health
care payment and remittance advice transaction (835). The statute
further allows the use of web-based technology for complying with
the requirements as long as the data content and rules of the
Minnesota Uniform Companion Guides are followed.
Electronic Funds
Transfer
Beginning second quarter 2011, Blue Cross and Blue Cross Blue
Shield of Minnesota and Blue Plus (Blue Cross) will no longer
print and mail any paper remittances. Providers will also not be
able to obtain a printed copy of the remittance through provider
services except for remittances produced before February 2010.
Providers must register through Availity to receive the electronic
835 or register for access to our provider portal, provider web selfservice
(PWSS) to view their remittance information. Providers
can register for both options. The full on-line view through the
portal via PWSS was available as of September 22, 2010.
A nonparticipating provider generally receives neither direct
reimbursement from Blue Cross nor a copy of the statement for
any member who has Blue Cross coverage. Members cannot
assign benefits to providers. We pay the member directly for
nonparticipating Minnesota or border providers. However, the
provider will be paid directly if the member has
PMAP/MinnesotaCare coverage.
Blue Cross and Blue Shield of Minnesota and Blue Plus offer
Electronic Funds Transfer (EFT). Instead of weekly checks with
your remits, you can now receive electronic payments directly into
your facility’s checking or savings account. The funds are securely
transferred via the Automated Clearinghouse (ACH) process.
Electronic payment will streamline your reconciliation process,
eliminate deposit delays due to check handling, and improve cash
flow.
To access a copy of the Provider Automatic Payment application,
please visit our website; click on the Provider icon and then forms.
9-2 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (11/02/11)

Reimbursement / Reconciliation
MNCare Tax Those fee schedules that are impacted by the MNCare tax already
have the 2 percent tax included.
Examples of fee schedules that do not include the MNCare tax are
those for Medicaid, Workers’ Compensation, HIAA, Federal
Employee Program, out-of-state providers, and some specific
provider types.
Inpatient Claims Paid
at DRG Rates
Blue Cross pays inpatient claims at DRG (Diagnosis-related
group) rates for most hospitals. Some rural hospitals may continue
to be paid at a percentage of charge.
About DRGs
The DRG reimbursement methodology has over 500 inpatient
categories of care, which are updated annually by the Centers for
Medicare and Medicaid Services (CMS). DRGs are a way of
categorizing inpatient hospital services by diagnosis groups that
have similar patterns of hospital resource use and similar lengths
of stay. DRG assignment is based on the patient’s principal and
secondary diagnoses, principal and secondary procedure codes,
age, sex and discharge status. Payments are based on the assigned
DRG case weight, multiplied by a base rate (conversion factor)
that Blue Cross negotiates with hospitals.
Coding Compliance
Coding compliance relates to the accuracy and completeness of the
ICD-9-CM diagnosis and procedure codes that are used to assign
DRGs and determine payment. Blue Cross requests that hospitals
establish adequate internal procedures to ensure the accuracy of
claims submissions. Blue Cross reserves the right to conduct
random chart audits on a sample of records to ensure that
diagnoses submitted justify the DRG and adhere to ICD-9-CM
coding rules. Coding errors that are determined to represent a
fraudulent claim may be subject to penalties.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (11/02/11) 9-3

Reimbursement / Reconciliation
Complication and Comorbidity
Defined
According to St. Anthony Publishing, a “complication” is a
condition that arises during a hospital stay and prolongs the length
of stay by at least one day in approximately 75 percent of the
cases. The same source defines “co-morbidity” as a preexisting
condition that, because of its presence with a specific diagnosis,
will cause an increase in length of stay by at least one day in
approximately 75 percent of cases. The condition must affect the
patient’s hospital care by requiring one or more of the following:
Clinical evaluation
Therapeutic treatment
Diagnostic studies or procedures
Increased length of stay
Increased nursing care and/or monitoring
Although there is a standard list of diagnoses that are considered
complications or co-morbidities, if the diagnosis does not require
one or more of the above services, it should not be listed as a
diagnosis. The physician must verify and document the conditions,
based on clinical findings and treatment in the record.
9-4 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (11/02/11)

Serious Preventable
Medical Errors
Reimbursement / Reconciliation
When the negligence, omission, or error on the part of provider
results in the subscriber incurring additional medical expenses no
payment will be made by Blue Cross for, nor shall provider bill
either Blue Cross or the subscriber for said additional medical
expenses. The National Quality Forum has defined certain events
as serious preventable medical errors, and these are the situations
for which no payment shall be made by Blue Cross or the
subscriber.
A listing of these events can be found at www.qualityforum.org.
This listing will be updated periodically by the National Quality
Forum.
Examples of serious preventable errors include:
Unintended retention of a foreign object in a patient after
surgery.
Patient death or serious disability associated with a medication
error (e.g., errors involving the wrong drug, wrong dose, wrong
patient, wrong time, wrong rate, wrong preparation or wrong
route of administration).
Surgery performed on the wrong body part.
Surgery performed on the wrong patient.
Wrong surgical procedure performed on a patient.
Infant discharged to the wrong person.
The Blue Cross and Blue Shield Association's listing of recognized
serious preventable errors can be found on the Association's
website at www.bcbs.com.
An implementation guide for appropriate identification of serious
preventable errors, including a list of ICD-9 CM codes used to
identify serious preventable errors and/or Hospital Acquired
Conditions on a claim can also be found at www.bcbs.com.
The Blue Cross and Blue Shield Association is an association of
independent Blue Cross and Blue Shield plans.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (11/02/11) 9-5

Reimbursement / Reconciliation
Remittance Advice
Introduction The provider remittance is made available every week and at
month end. The remittance will include claims that are processed
or adjusted before the end of the day Friday. You will receive one
remittance for each NPI and each type of claim (i.e. institutional,
professional). You will receive a separate remittance for Blue
Cross members and Blue Plus members, even if you are not a Blue
Plus participating provider. The Blue Cross and Blue Plus
remittances may vary slightly.
Sample PDF
Remittance Advice
2006 Remittance
Advice Change
Remember to always retain a copy of your remittance to meet
HIPAA requirements in a central location for easy retrieval, as
they are an essential resource for your business.
A sample of the PDF version of the provider remittance with field
descriptions is on our website.
The Health Care Administrative Simplification Act of 1996
allowed Minnesota health care providers and payers the chance to
implement administrative standards and simplified procedures
throughout the industry. A portion of the Act required payers to
develop and implement a uniform paper Explanation of Health
Care Benefits (EOB) and Remittance Advice report (remit). The
Act prescribes specific data fields that must appear on the EOB
and remit.
ANSI Codes Blue Cross and Blue Plus uses all the conventions addressed in the
“Minnesota Paper Explanation of Benefits and Uniform Paper
Remittance Advice Report” manual developed by the
Administrative Uniformity Committee (AUC) in our PDF version
of the remittance.
A copy of the manual is available on their website at:
www.health.state.mn.us/auc/eobremitmanual2007.pdf or
Minnesota’s Bookstore at (651) 297-3000 or 1-800-657-3706.
The guide sets forth the standard approach to be adopted by payers
and providers.
9-6 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (11/02/11)

Questions and Answers 1. Where will adjusted claims appear?
Reimbursement / Reconciliation
They will appear as claim transactions on the remittance
advice. You will see negative amounts on the cancel of the
original claim followed by a new claim to show the final status.
2. How can I identify adjustments in the remittance?
The claim number will be the same as in the original statement,
except the last three digits. For example: If the original claim
ended in 000 the adjusted claim will end in 010. If it needs to
be adjusted again, it will end in 020, etc. If we then make
additional or adjusted payment for that claim, the newly
processed claim will be printed above the original claim.
3. What is a credit balance?
When the amount of this payment is not enough to cover the
credits, a credit balance will occur. If the credit balance
occurred on this statement, this amount the will appear in the
PDF version of the remit in field #27 along with a code in field
#28. If there were credit balances from previous statements,
that information will be reflected in fields #27 and #28. An
Accounts Receivable Recoupment Report is sent separately
and prior to the remittance reflecting which claims are being
recouped in this statement period. This report is only sent when
recoupments will be made.
A credit for a Blue Plus member will only be recouped from
the Blue Plus remittance and a credit for a Blue Cross member
will only be recouped from the Blue Cross remittance.
4. How do I use the Accounts Receivable Recoupment Report?
This report is sent out under separate cover from the weekly
remittance and lists the claims that will be recouped that week.
The amount listed on this report will be reflected in the weekly
remittance. Remember to keep this report in a central location
for easy retrieval.
5. Do I have to credit the member’s account based on the
Accounts Receivable Recoupment Report?
If you already credited the member’s account based on the
remittance that reflected the adjustment, then do not adjust the
member’s account again. This is an internal workflow for your
office. Adjusting the member’s account using both the weekly
remittance and the Accounts Receivable Recoupment Report
may result in duplication.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (11/02/11) 9-7

Reimbursement / Reconciliation
Questions and Answers
(continued)
6. What if there is a claim on my remittance for a patient that
is not ours?
Request an adjustment by contacting provider services. Please
do not send our payment check back to us or send us a refund
check unless we have requested it from you.
7. Why does the check I received not match the amount listed
under Net Payment Activity on the statement?
Less Prior Credit Balances and Less Current Credit Balances
will be subtracted from the Net Payment Amount. Your check
should match the amount listed in the Payment Due field on
the statement.
8. What can I bill the patient and how can I identify it on the
statement?
The Patient Responsibility field reflects the total patient
liability. This is the amount that the patient is responsible to
pay. However, you may have already billed the member for
copayments up front.
9. What do I have to write-off and how can I identify it on the
statement?
The group code 'CO' signifies a provider contractual
obligation. Any amounts associated to the use of this code
should be written off.
10. Do members receive their Explanation of Health Care
Benefits (EOB) at the same time as providers?
No, the member’s EOB is mailed daily and provider’s
remittances are sent or posted weekly. However, we mail
members’ EOBs monthly if there is zero member liability and
payment was made to the provider. If a member references a
claim that you haven’t received notice on yet, it should be on
your next remittance.
11. How can I identify BlueCard ® claims?
The BlueCard claims may be identified by the three digit
alpha-prefix on the member’s identification number. BlueCard
member's prefix will not be XZA.
9-8 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (11/02/11)

Questions and Answers
(continued)
12. What does the claim number represent?
Reimbursement / Reconciliation
The claim number is a sequence of numbers that identifies each
claim. Knowing what the claim number consists of may assist
you in better understanding the claim. The information below
describes a claim number.
Example: Claim number 5109361034020
5109= Julian date the claim was entered into our claims
processing system. i.e., 109th day of 2005
361034= the sequence number for claims entered on that date
020= The first and third positions reflects a claim has been
split. If a claim is split, we are unable to process a claim as one
claim so we process it as two. Two main reasons to split a
claim are when benefits have changed in the middle of the
claim or there are too many lines for us to process it as one
claim.
The second position reflects if the claim has been adjusted (i.e.,
0= original claim, 1= claim adjusted the first time, 2= claim
adjusted the second time, etc.)
13. How do I request an adjustment or inquiry?
An adjustment should be requested when you notice the
adjudication error. Please remember that if data on the claim
needs to be changed, you must send a complete replacement
claim rather than request an adjustment.
You can request an adjustment by:
Submitting a request through provider web self-service
Fax in the Provider Services Inquiry fax form to:
(651) 662-2745
Mail in a request to:
Blue Cross and Blue Shield of Minnesota
P.O. Box 64560
St. Paul, MN 55164-0560
For inquiries:
Provider web self-service is found at:
www.providerhub.com
Call BLUELINE at (651) 662-5200 or 1-800-262-0820
Call provider services at (651) 662-5200 or
1-800-262-0820. Please wait 30 days before checking the
status of a claim or adjustment.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (11/02/11) 9-9

Reimbursement / Reconciliation
Questions and Answers
(continued)
14. What do I do with interest payments?
Interest payments that you receive should be posted to a
miscellaneous account. This is money that is yours and should
not be posted to the account of the member it pertains to. By
posting this money to a member’s account they may end up
with a credit.
15. Are there any limits for making adjustments?
Blue Cross may make, and providers may request, corrective
claim adjustments (recoupments or additional payments) to
previously processed claims for services within 12 months of
the date a claim is paid or denied unless the adjustment is made
for the following circumstances (and thus are not limited to this
12-month period):
One or more insurer is involved, whether primary or
secondary (i.e., Medicare secondary payer, no-fault
automobile coverage, subrogation, coordination of benefits,
workers’ compensation, TEFRA, etc.)
The adjustment is required due to provider error (i.e., the
provider should not have billed for services, a claim was a
duplicate of a claim previously paid, fraud, incorrect
billing, etc.)
The adjustment is required pursuant to applicable law,
regulation, rule, order or contractual requirement (i.e.,
BlueCard claims); or
The adjustment is required as part of a contractual
settlement obligation with the provider.
Note that provider errors or data changes require a
replacement claim or cancel claim be submitted within six
months of the last adjudication date.
Corrective adjustment requests must be received within 12
months from the date the claim was last paid or denied by
Blue Cross.
9-10 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (11/02/11)

Reimbursement / Reconciliation
Remit Balancing Tips Amounts reported in the remittance, if present, must balance at
three levels: service line, claim and total remittance.
Service Line Balancing
Although the service payment information is situational, it is
required for all professional claims or anytime payment
adjustments are related to specific lines from the original
submitted claim. When used, the submitted service lines minus the
sum of all monetary adjustments must equal the amount paid for
the service line.
Charge – Adjustment Amount = Payment Amount
Claim Balancing
Balancing must occur at the claim level so that the submitted
charges minus the sum of all monetary adjustments equals the
claim paid amount.
Charge – Adjustment Amount = Claim Payment Amount
Remit Balancing
Within the transaction, the sum of all payments minus the sum of
all adjustments equals the Payment Amount.
Sum of all Payments totaled – the Sum of all
Adjustments = Total payment amount of this remittance
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (11/02/11) 9-11

Reimbursement / Reconciliation
Accounts Receivable Recoupment Report
Introduction The Accounts Receivable Recoupment Report lists the amount
credited, amount recovered, and any balance due on claims for
your patients. It will only be sent if there are funds to be recovered
that week. All the recouped claims for the week (Prior Credit
Balances and Current Credit Balances from the remittance) will be
listed on the Accounts Receivable Recoupment Report.
The Report is sent out weekly under separate cover and in advance
of the remittance. Remember to always keep these reports in a
central location for easy retrieval.
9-12 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (11/02/11)

Accounts Receivable
Recoupment Report
Reimbursement / Reconciliation
Following is a copy of the Accounts Receivable Recoupment
Report. Field descriptions follow the report.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (11/02/11) 9-13

Reimbursement / Reconciliation
Field Descriptions A brief explanation of the fields on the Accounts Receivable
Recoupment Report follows:
Name — Name and address of the billing provider.
Page — Page number of the report.
Date — This date coincides with the Statement of Provider
Claims Paid. The information found on this report reflects the
activity which occurred on the Statement of Provider Claims
Paid with this same date.
NPI — National Provider Identifier.
Recovery Date — Credit activity may take place during the
week but actual transactions are not processed until Friday.
This date will reflect the Friday’s date prior to the date of your
“Statement of Provider/Institutional Claims Paid.”
Sub-ID — Member identification number under which the
credit claim activity occurred. If amounts are being recouped
due to a settlement of which you were previously notified.
Patient Name — Name of the patient.
Claim Number — Number of the claim which was overpaid
or paid in error by us.
Date Created — Actual date the claim was adjusted by us.
Service Date – Date of service on the claim.
Credit Amount — Amount we need to recover from this
claim. If we were unable to recoup the entire amount of the
claim from previous statements, this amount will list just the
balance remaining.
Amount Recovered — Amount being recouped on this
statement. This amount is deducted from the Net Payment on
the “Statement of Provider/Institutional Claims Paid.”
Balance Due — Amount we still need to recoup from future
statements. If there is a balance, the claim will be listed in
future reports when it is recouped.
Total Credit Activity — Amount of overpayment identified
prior to amounts recouped in this statement.
Total Recovered — The total amount of overpayments
deducted from your weekly Statement of
Provider/Institutional Claims Paid for the week.
Balance Due — If the overpayment exceeds what we are
recouping for that statement, the amount still due to us will be
listed here.
9-14 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (11/02/11)

Table of Contents
Chapter 10
Appeals
Provider Appeals...................................................................................................................... 10-2
Introduction..........................................................................................................................10-2
Post Service Claim Appeals.................................................................................................10-2
Appeals of Processed Claims............................................................................................... 10-3
Voluntary Second Appeal.................................................................................................... 10-3
Submitting Requests for Post Service Claim Appeals.........................................................10-4
Prior Authorization and Preadmission Notification Appeal Process...................................10-4
Prior Authorization and Preadmission Notification Appeal ................................................ 10-4
Urgent/Expedited Appeals...................................................................................................10-5
Coding Appeals.................................................................................................................... 10-5
BlueCard ® Appeals ..............................................................................................................10-6
BlueCard Appeal vs. Adjustments....................................................................................... 10-6
Appealing Claims Processed by the Member’s Plan ........................................................... 10-6
Supporting Documentation .................................................................................................. 10-7
Utilization Review Decision Appeal ...................................................................................10-8
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12) 10-1

Appeals
Provider Appeals
Introduction Providers are eligible to appeal:
Post Service Claim
Appeals
Post service claim appeals
Prior Authorization and Preadmission Notification denials
Coding appeals
For information regarding settlement appeals, refer to your
provider agreement.
For information regarding submission of replacement or cancel
claims, refer to Chapter 8 in this manual.
Instructions for the submission of appeals are listed in this chapter.
Please read the information carefully to ensure your appeal is
reaching the appropriate area within Blue Cross and Blue Shield of
Minnesota (Blue Cross) as that will allow for an efficient and
timely review of your request.
A post service claim appeal is a written request for review.
The Minnesota Uniform Companion Guides, version 4.0, dated
March 2009, Section 4.2.3.2, define an appeal as “Provider is
requesting a reconsideration of a previously adjudicated claim but
there is no additional or corrected data to be submitted.”
Post service claim appeals require the provider to include with the
request documentation of items such as chart notes, medical
records, operative reports and letters of medical necessity. Appeals
present detailed information in an attempt to change a previous
decision made by Blue Cross.
All post service claim appeals must be submitted on the AUC
Appeal Request Form available on the AUC web site,
www.health.state.mn.us.auc, along with the supporting
documentation and must be mailed or faxed to the Consumer
Service Center.
A post service claim appeal must be requested within 90 days of
the date claim notification is issued. There is no limit on the dollar
amount for an initial appeal.
A standard claim appeal submitted with a completed AUC appeal
form and attached supporting documentation will be completed
within 60 days of receipt. The appeal decision is final unless the
charges in question exceed $500.00. At that time, a voluntary
second level review is available.
10-2 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12)

Appeals of Processed
Claims
Voluntary Second
Appeal
Situations brought to appeal include the following categories:
Benefit determinations
Claims processing
Determinations of allowed amounts
Provider profiles
Timely filing denials
Services denied due to lack of medical necessity
Appeals
This appeal process does not apply to settlement appeals, medical
necessity and prior authorization denials occurring prior to claim
submission.
Voluntary Second Appeals must be filed within 60 days of the
notification upholding the decision of the initial appeal. To be
eligible for a voluntary second appeal, the amount at issue must be
$500.00 or more. Calculate the amount at issue by subtracting the
deductible, coinsurance, and paid amount from the billed charge.
For example:
Billed amount $2,000.00
- (deductible) 500.00
- (coinsurance) 200.00
- (paid amount) 500.00
Amount at issue $ 800.00
If the amount in question is $500.00 or more then this appeal
review may be conducted by the Consumer Service Center as well
as Integrated Health Management.
Claims for the same patient or multiple patients relating to the
same category can be aggregated at this level (you may combine
two or more claims to meet the $500.00 amount-in-controversy
requirement).
Voluntary second appeals must be submitted with additional
information over and above what was submitted with the initial
appeal. These requests must also be submitted on an AUC Appeal
form and should note “Secondary Appeal” on the form.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12) 10-3

Appeals
Submitting Requests
for Post Service Claim
Appeals
Prior Authorization and
Preadmission
Notification Appeal
Process
Prior Authorization and
Preadmission
Notification Appeal
Post service claim appeals may be mailed or faxed.
Mailing address:
Blue Cross and Blue Cross Blue Shield of Minnesota
Attn: Consumer Service Center
PO Box 64560
St. Paul, MN 55164-0560
Fax: (651) 662-2745
You may appeal a prior authorization request or preadmission
notification request denied as medically unnecessary. Your request
may be initiated by letter or telephone. Written requests should be
addressed to the Consumer Service Center using the address or fax
number provided in the denial letter. An appeal reviewer will
review the case and make a final determination.
You may appeal a prior authorization request or a preadmission
notification request denied for benefit administration within 30
days of notification. Your request must be in writing and should be
addressed to:
Blue Cross and Blue Shield of Minnesota
Attn: Consumer Service Center
P. O. Box 64560
St. Paul, MN 55164-0560
You may also fax your denied prior authorization appeals to
(651) 662-9517.
When coverage is denied for Prior Authorization or Preadmission
Notification based on medical necessity, Blue Cross notifies the
provider by telephone and/or sends letters to the member, hospital
and physician. The physician, member or facility may appeal the
denial. The appeal may be initiated either by letter or by telephone.
Blue Cross’ review is only a medical necessity review and is
subject to all other limitations in the member’s contract. Services
may be denied because of exclusions, limitations on preexisting
conditions, and medical necessity requirements contained in the
member’s contract. These contract provisions will prevail over a
medical necessity decision. The decision to continue an inpatient
stay or services ultimately rests with the patient and the physician.
During the appeal process, all available information is provided to
a physician reviewer who is board certified in the same or similar
general specialty as typically manages the medical condition or
treatment and was not involved in the original determination.
10-4 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12)

Urgent/Expedited
Appeals
Appeals
An urgent appeal is done when an initial or continued treatment is
dependent on a quick determination. Urgent is defined as medical
care or treatment with respect to which the application of the time
periods for making nonurgent care determinations:
1. Could seriously jeopardize the life or health of the claimant or
the ability of the claimant to regain maximum function,
although it may not rise to the level of being a life-threatening
circumstance, or
2. In the opinion of a physician with knowledge of the claimant’s
medical condition, would subject the claimant to severe pain
that cannot be adequately managed without the care or
treatment that is the subject of the claim.
Urgent appeals are completed within 72 hours of receipt of the
appeal request, or sooner, based on the medical exigencies of the
case. Providers should contact the Blue Cross clinician who signed
the denial letter to initiate an urgent appeal.
Coding Appeals Blue Cross’ coding edits are updated at minimum annually to
incorporate new codes, code definition changes and edit rule
changes. All claims submitted after the implementation date of this
update, regardless of service date, will be processed according to
the updated version. Where Medicare’s CCI (Correct Coding
Initiative) edits are identical, we will consider the appeal with
additional documentation; however, the issue is likely to be
upheld. Adjustments, and/or request refunds will not be made
when processing changes are a result of new code editing rules due
to a software version update. Notice of this update will be
published in the Provider Press and/or a Provider Bulletin.
Blue Cross has adopted a standard process to review coding edit
appeals and providers have the right to appeal with additional
information. Appeals received without additional information will
not be reviewed. The denial will be upheld.
If you have a question or appeal about our policy regarding a
particular coding combination, provide a written statement of the
concern, along with the following and/or documentation normally
required for a medical review.
Written explanation supporting the procedures submitted, i.e.,
specific references, specialty specific criteria
Documentation from a recognized authoritative source that
supports your position on the procedure codes submitted
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12) 10-5

Appeals
Coding Appeals
(continued)
Once received, the inquiry or appeal will be reviewed and if
necessary, forwarded to the Integrated Health Management
department for determination. The review may result in approval
or denial of the claim, based on review of the information
submitted.
Note: Requests to add modifier -24, -25 or -59 to a denied service
must be submitted as replacement claims. All supporting
documentation must also be attached to the replacement
claim.
Appeal requests may be faxed or mailed.
Send your appeal request to the following address:
Blue Cross and Blue Shield of Minnesota
Attn: Provider Coding Appeals
P.O. Box 64560
St. Paul, MN 55164-0560
Fax appeal requests to: (651) 662-2745
BlueCard ® Appeals Appeals for BlueCard claims are handled through Blue Cross.
BlueCard Appeal vs.
Adjustments
Appealing Claims
Processed by the
Member’s Plan
Generally, you will not find the appeal process any different. If
coordination is required with the member’s Plan, we will
coordinate it. Appeals for timely filing of BlueCard claims must be
submitted to the patient’s Blue Plan.
BlueCard requires that for the following circumstances, new
claims must be submitted. Adjustments /appeals cannot be
reviewed in these instances:
Change an incorrect Individual Provider Number or NPI
Change an incorrect member ID number, including alpha
prefix
Claim was sent in for a patient that is not yours
Claims that are returned to you with either a yellow or green
form attached
Appeals for claims processed by the member’s plan are also
handled by them. However, you should send a completed AUC
Appeal Form and the applicable attachments to Blue Cross and we
will work with the member’s plan to facilitate your request.
10-6 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12)

Supporting
Documentation
Appeals
The two key elements for submitting documentation with appeal
requests are the patient’s name and the date of service. Both should
be included on each page of the documentation submitted.
Additionally, the documentation should correspond with the dates
of service at issue.
When the provider submits the appealed claim, the responsibility
for gathering and submitting documentation that supports the
service rests with the provider. We will offer guidance and
assistance as necessary, but the responsibility for identifying what
is needed and where it is located is yours.
The list below includes common types of claim denials/reductions
that may be submitted for appeal and the sources of documentation
suggested for each type. This information is presented as a guide to
assist you and is not a complete listing.
Type of Denial or
Reduction Documentation
Surgical
Complications
Operative report, chart notes, letter
stating rationale for complication
Medical Necessity Medical records and rationale for service
performed
Investigative Medical records and rationale for service
performed
Cosmetic Medical records and rationale for services
DRG/Category Code Rationale for questioning of payment
Private Room Notes, doctor’s order and letter of
medical necessity
Allowed Amount for
unlisted codes
Allowed Amount – for
modified CPT/HCPCS
codes.
Allowed Amount –
excluding unlisted
codes.
Chart notes or invoice, NDC number and
a letter to review allowance for an
unlisted code. This is independent from
medical necessity review process.
Note: An invoice is required for DME
or supply allowance appeals.
Chart notes, letter and operative report
when applicable to review allowance.
Copy of fee schedule or provider
agreement.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12) 10-7

Appeals
Supporting
Documentation
(continued)
Utilization Review
Decision Appeal
Type of Denial or
Reduction Documentation
Incompatible
Diagnosis
Letter requesting review of codes that are
denying as incompatible and related notes
Timely Filing Documentation supporting submission of
a claim after timely filing, such as
secondary coverage, patient expired
during timely filing period, or DME
rental charges that span the timely filing
period. Timely filing is addressed in
Chapter 8.
Coding Edit (Refer to
Chapter 11 for details)
All supporting documentation for
corresponding date of service.
Under current external review provisions, Provider or any other
authorized representative may initiate an external review appeal on
behalf of a Subscriber, with the express written authorization of
said Subscriber. Provider and Blue Cross agree that this appeal
process is binding, unless the Subscriber initiates an external
appeal related to Utilization Review decisions. In the event that a
Subscriber, a duly authorized representative of the Subscriber, or a
Provider initiates an appeal related to Utilization Review
decisions, Blue Cross shall abide by all applicable external review
requirements of Minnesota Statutes, Section 62Q.73.
10-8 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12)

Chapter 11
Coding Policies and Guidelines
(Coding)
Table of Contents
Coding ....................................................................................................................................... 11-2
Overview..............................................................................................................................11-2
HCPCS Codes...................................................................................................................... 11-2
CPT/Level I..........................................................................................................................11-3
Level II HCPCS ................................................................................................................... 11-5
ICD-9-CM............................................................................................................................11-7
Revenue Codes..................................................................................................................... 11-9
Compatibility .......................................................................................................................11-9
Preventive Care Services ...................................................................................................11-10
Preventive Services Required Under the PPACA .............................................................11-13
General Guides................................................................................................................... 11-22
Zero-billing ........................................................................................................................ 11-22
Coding Edits ........................................................................................................................... 11-23
Overview............................................................................................................................ 11-23
Edit Descriptions................................................................................................................ 11-23
Mutually Exclusive Procedures .........................................................................................11-25
Incidental Procedures.........................................................................................................11-26
Medical Visits on the Same Day as Surgery......................................................................11-27
Global Surgical Package – Pre- and Postoperative Services .............................................11-28
Units of Service Validation and Restriction ......................................................................11-29
General Claims Processing Information ............................................................................ 11-30
Medical and Surgical Supplies...........................................................................................11-30
Multiple Surgery Guidelines..............................................................................................11-30
Patient Billing Impact ........................................................................................................11-30
Coding Appeals.................................................................................................................. 11-31
Helpful Coding Tips ..........................................................................................................11-32
Coding Immunizations and Injections ...............................................................................11-32
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Coding Policies and Guidelines (Coding)
Coding
Overview Blue Cross and Blue Shield of Minnesota (Blue Cross) requires
submission of valid codes to report medical services and supplies
on both professional and institutional claims. This includes
Healthcare Common Procedural Coding System (HCPCS) codes,
International Classification of Diseases, 9th Revision, Clinical
Modification (ICD-9-CM) diagnosis and procedure codes and
Revenue codes.
11-2
The Health Insurance Portability and Accountability Act (HIPAA)
Transaction and Code Set regulation stipulates submission and
acceptance of approved medical code sets. HCPCS and ICD-9-CM
codes are among the approved HIPAA medical code sets and must
be valid for the actual date of the service. If a HCPCS or ICD-9-
CM code is not valid for the date of service, the claim will be
returned or denied.
Revenue codes are a data element of the institutional claim (837I
or UB-04) and must be valid for the date of submission. If a
Revenue code is not valid on the date submitted, the claim will be
returned or denied.
HCPCS Codes The HCPCS coding system was developed by CMS (Centers for
Medicare and Medicaid Services) to standardize coding systems
used to process claims for all payers, including Medicare and
Medicaid. HCPCS is a two level coding system-Level I, a.k.a.,
CPT, and Level II, alpha-numeric codes.
All nationally developed codes are accepted; however, coverage is
not guaranteed and other restrictions may apply. Services may
deny for various reasons including a subscriber contract exclusion
or service limitation, Blue Cross corporate or medical policy, or
subject to standardized coding edits.
HCPCS codes are updated several times throughout the year. The
primary update is January of each year. CMS provides updates to
Level II codes on a quarterly basis. In addition to January, code
updates are done in April, July, and October. CPT codes are
generally updated only in January; however, the AMA can release
codes early and make codes slated for the next year’s publication
available in the prior July.
You will be notified of coding updates by Bulletin or the Provider
Press newsletter as to effective date of acceptance by Blue Cross.
Reimbursement of new HCPCS/CPT codes billed on professional
claims (CMS HICF/837P) will be based on of the then current
standard Blue Cross fee schedule allowed amount unless explicitly
stated otherwise.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (07/12/12)

Blue Cross Blue and Shield of Minnesota Provider Policy and Procedure Manual (07/12/12)
Coding Policies and Guidelines (Coding)
CPT/Level I Level I or CPT (Current Procedural Terminology) codes are
developed and maintained by the American Medical Association.
Each procedure is identified with a five-digit numeric or numericalpha
code. CPT is a set of codes, descriptions and guidelines
intended to describe procedures and services performed by
physicians and other health care providers. Inclusion or exclusion
of a procedure does not imply any health insurance coverage or
reimbursement policy.
There are eight main sections to the CPT manual, including
subsections with anatomic, procedural, conditions or descriptor
subheadings. All listings are in numeric order except for
Evaluation and Management (E/M) codes. E/M codes are the most
frequently used and are listed first in the CPT manual
Section Numbers and Sequences:
E/M.........................................................99201 to 99499
Anesthesiology.......................................00100 to 01999 and 99100
to 99140
Surgery ...................................................10021 to 69990
Radiology ...............................................70010 to 79999
Pathology and Laboratory......................80047 to 89398
Medicine (except Anesthesiology).........90281 to 99199 and 99500
to 99607
Category II Codes ..................................0001F to 7025F
Category III Codes .................................0019T to 0301T
Modifiers
A modifier is used to indicate that the service or procedure that has
been performed has been altered by some specific circumstance
but has not changed the definition or code. A complete listing of
modifiers is found in Appendix A of CPT. Level I codes are not
limited to CPT modifiers. HCPCS Level II modifiers may also be
used with Level I codes and/or in combination with CPT
modifiers.
Genetic Testing Code Modifiers are found in Appendix I of CPT.
11-3

Coding Policies and Guidelines (Coding)
CPT/Level I
(continued)
11-4
CPT Format
CPT codes are five characters in length (either all numeric or
numeric-alpha) and designed as stand-alone descriptions of
medical procedures. Some procedures in CPT are not printed in
their entirety but refer back to a common portion of the procedure
listed in the preceding entry. These are sometimes referred to as
indented procedures.
For example:
97010......Application of a modality to one or more areas; hot or
cold packs
97012......Traction, mechanical
The common part of the code 97010 is before the semicolon and is
also considered part of the code 97012. The full narrative for
97012 is “Application of a modality to one or more areas; traction,
mechanical.”
Guidelines
Guidelines are presented at the beginning of each of the main eight
sections. Some section subheadings may contain instructions or
information specific to those codes.
Code Symbols
Certain symbols may precede a code to indicate additional
information:
New CPT codes will be preceded by a bullet () symbol.
Revised CPT codes will be preceded by a triangle (▲) symbol.
Add-on CPT code will be preceded by a plus () symbol.
Codes that include conscious sedation will be preceded by a
target () symbol.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (07/12/12)

Blue Cross Blue and Shield of Minnesota Provider Policy and Procedure Manual (07/12/12)
Coding Policies and Guidelines (Coding)
Level II HCPCS Level II HCPCS are developed and maintained by CMS. Level II
consists of codes for supplies, materials, injections and services.
Each Level II code is identified with a five character
(alphanumeric) code.
Level II codes are generally referred to simply as HCPCS codes to
differentiate them from the Level I (CPT) codes. HCPCS codes are
generally used because CPT has a limited code selection for these
areas. All listings are in alpha category order except for modifiers.
Format
HCPCS codes are five characters in length, consisting of one alpha
and four numeric characters. Level II codes start with alpha
characters A through V and relate to these nationally defined
categories:
A0000-A0999........Transportation Services Including Ambulance
A4000-A8999........Medical and Surgical Supplies
A9000-A9999........Administrative, Miscellaneous and
Investigational
B4000-B9999 ........Enteral and Parenteral Therapy
C1000-C9999 ........Outpatient PPS
D0000-D9999........Dental Procedures
E0100-E9999 ........Durable Medical Equipment
G0000-G9999........Procedures/Professional Services (Temporary)
(including Injections, Laboratory, Medical
Services, Supplies)
H0001-H2037........Alcohol and Drug Abuse Treatment Services
(includes prenatal care codes)
J0000-J9999 ..........Drugs Administered Other than Oral Method
(J0000-J8499 – Other than Chemotherapy,
J8500- J8999 – Oral Chemotherapy Drugs,
J9000-J9999-Chemotherapy Drugs)
K0000-K9999........Temporary Codes (for DMERCS including
Durable Medical Equipment, Orthotics &
Prosthetics, Supplies)
L0000-L4999 ........Orthotics Procedures and Devices
L5000-L9999 ........Prosthetic Procedures
11-5

Coding Policies and Guidelines (Coding)
Level II HCPCS
(continued)
11-6
M0000-M0301 ......Medical Services
P0000-P9999.........Pathology and Laboratory (including Blood
Products)
Q0000-Q9999........Q Codes (Temporary) (including Injections,
Laboratory, Occupational Therapy, Physical
Therapy)
R0000-R5999 ........Diagnostic Radiology Services (including
Portable X-ray)
S0000-S9999.........Temporary National Codes (Non-Medicare)
T1000-T9999 ........National T Codes Established for State
Medicaid Agencies
V0000- V2799.......Vision Services
V5000- V5399.......Hearing Services
Modifiers
A modifier is used to indicate that the service or supply has been
altered by some specific circumstance but has not changed the
definition or code. A complete listing of modifiers is found as an
appendix to the HCPCS manual. Level II codes are not limited to
HCPCS modifiers. CPT modifiers may also be used with Level II
codes and/or in combination with HCPCS modifiers.
Code Changes
New HCPCS codes will be preceded by bullet () symbol.
Revised HCPCS codes will be preceded by a triangle ()
symbol.
Reinstated HCPCS codes will be preceded by a circle ()
symbol.
Reinstated codes were previously deleted codes that have been
reactivated.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (07/12/12)

Blue Cross Blue and Shield of Minnesota Provider Policy and Procedure Manual (07/12/12)
Coding Policies and Guidelines (Coding)
ICD-9-CM ICD-9-CM is a statistical classification system that arranges
diseases, injuries and procedures into groups. Most ICD-9-CM are
numeric and consist of three-, four- or five-digit numbers and a
description. The coding structure is revised approximately every
10 years by the World Health Organization. Annual updates,
effective October 1, are published by NCVHS and CMS.
Code Changes (not all publishers will include this information)
New ICD-9-CM codes will be preceded by a bullet () symbol.
Revised ICD-9-CM codes will be preceded by a triangle ()
symbol.
Format
ICD-9-CM consists of three volumes:
Volume I - The Tabular List
Volume I is a numeric listing of diagnosis codes and descriptions
consisting of seventeen chapters that classify diseases and injuries.
In addition, two sections of supplementary codes (V and E codes)
are included.
Most diagnosis codes are four- or five-digit codes. The base ICD-
9-CM diagnosis code consists of three digits, which may be further
defined or classified by a fourth or fifth digit following a dot (this
divides and identifies the base diagnosis). For example: 738.1 is
the diagnosis “Other acquired deformity of head.” “Zygomatic
hyperplasia” is coded as “738.11”. The addition of “1” specifically
defines the acquired deformity. Only valid diagnoses, submitted to
their full specificity, are accepted. If a fourth or fifth digit applies
to a specific diagnosis code, it must be submitted.
Volume 2 - The Alphabetical Index
Consists of an alphabetic list of terms and codes.
11-7

Coding Policies and Guidelines (Coding)
ICD-9-CM (continued) Volume 3 - Procedures: Tabular List and Alphabetic Index
11-8
Volume 3 is a numeric listing of procedure codes and descriptions
consisting of 17 chapters containing codes and descriptions for
surgical procedures and miscellaneous diagnostic and therapeutic
procedures. Codes from Volume 3 are intended only for use by
hospitals for inpatient services.
ICD-9-CM procedure codes are two-, three- or four-digit codes.
The base ICD-9-CM procedure code consists of two digits that
may be further defined or classified by a third or fourth digit
following a dot (this divides and identifies the base procedure). For
example: 50 is the procedure “Operations on liver.” “Closure of
laceration of liver” is coded as “50.61.” The addition of “.61”
specifically defines the liver operation. Only valid procedures
submitted to their full specificity, are accepted. If a third or fourth
digit applies to a specific procedures code, it must be submitted.
Linking/Pointing or Sequencing
In the professional claim record there are two diagnosis elements -
one is at the header level of the claim and the other is at the line
level and points to the values populated at the claim level. In the
837P electronic transaction record the Diagnosis Code Pointer is
found in the2400 loop - SV107-1, SV107-2, SV107-3, SV107-4.
The primary diagnosis for the service performed must be
appropriately linked to that service, especially if more than one
diagnosis relates to a line item. Up to eight diagnoses can be
submitted per professional claim and up to four of those can be
linked to a detail service line; however, adjudication is based on
the first linked diagnosis.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (07/12/12)

Blue Cross Blue and Shield of Minnesota Provider Policy and Procedure Manual (07/12/12)
Coding Policies and Guidelines (Coding)
Revenue Codes Revenue codes are developed by the National Uniform Billing
Committee (NUBC) and are used to identify specific
accommodation charges, ancillary service charges, or a type of
billing calculation. They are only to be submitted on the
institutional electronic claim format (837I).
Format
Revenue codes are four digits in length. The first three digits
define the category and the fourth digit defines the subcategory. It
is important for the subcategory to be properly defined for
appropriate payment. For example: 012X is the category for
“Room & Board-Semi-Private (Two Bed)”. While 012X indicates
the type of accommodations it does not identify the department or
area in the hospital where the patient is staying. However, the code
0122 (Obstetrics (OB) would properly indicate a semiprivate room
in the OB.
The list of revenue code is extensive and can be found in the
NUBC UB 04 manual under FORM LOCATOR
SPECIFICATIONS, form locator 42.
HIPAA transaction standards require submission of HCPCS/CPT
codes on outpatient facility claims. Guidelines for submission of
HCPCS/CPT codes including modifiers can be found in the UB-04
manual under FORM LOCATOR SPECIFICATIONS, form
locator 44.
Compatibility HCPCS and ICD-9-CM Codes
Blue Cross requires that diagnosis codes and procedures performed
be compatible. These conditions are identified separately not only
to assure correct coding, but also appropriately apply benefits.
A chart of injury, maternity and behavioral health conditions and
the compatible diagnosis codes or ranges is found below. Note that
this is a general guide only and is not all inclusive. All diagnoses
must be reported to the fullest specificity.
Condition Compatible Diagnosis Code/Code
Category
Injury 800-977, 980-994, V15.51, V15.59,
V15.6, V66.4, V67.4, V71.3-V71.4,
V71.6
Maternity 630-677, V22-V24, V27, V28
Chemical dependency 303-305. V79.1
Psychiatric care 291-302, 306-319, V11, V40, V70.1-
V70.2, V71.01-V71.09
11-9

Coding Policies and Guidelines (Coding)
Compatibility
(continued)
Preventive Care
Services
11-10
Revenue Codes
Revenue codes must also be compatible with the type of facility,
place of service and type of claim. On the 837 institutional claim,
this is the claim facility type code and claim frequency code. Some
revenue codes are very specific to the place where the service was
rendered.
For example, the TOB 0111 indicates an original claim for a
hospital inpatient admission through discharge.
Administration of Blue Cross’ preventive care policy includes a
list of defined preventive care services according to evidencebased
guidelines. Payment for listed services would be subject to
the subscriber’s coverage options for preventive care and cancer
screening. Variations in payment may occur based on self-insured
dollar and service limits. Benefits should be verified through use
of the electronic eligibility transaction, our provider web self
service site at www.providerhub.com or through BLUELINE.
Services considered preventive
If a patient presents to have these services performed for
preventive purposes, claims will be adjudicated as preventive care
provided the reason for the visit on the claim is listed as
preventive, regardless of outcome. Blue Cross’ administrative
guidelines are as follows:
Service Frequency (does
not apply to Blue
Plus)
Abdominal Aortic
Aneurysm (AAA)
screening
Vision Screening:
Glaucoma, Acuity,
Refraction
Clinical Practice/
Guidelines
1 per lifetime Blue Cross
1 per year ICSI
Hearing 1 per year ICSI
Standard immunizations Per schedules
determined by
clinical
guidelines
CDC/ACIP
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (07/12/12)

Preventive Care
Services (continued)
Service Frequency (does
not apply to Blue
Plus)
Radiology: Osteoporosis
Screening
Laboratory Services:
Cholesterol/Lipid Profile,
Urinalysis
Blue Cross Blue and Shield of Minnesota Provider Policy and Procedure Manual (07/12/12)
Coding Policies and Guidelines (Coding)
1 per year ICSI
As recommended
by physician
Diabetes Screening As recommended
by physician
STD Screening: HIV,
Chlamydia, Gonorrhea,
Syphilis
Preventive Medical
Examination for Adults
including Skin Exam,
Testicular Exam, Prostate-
Digital Rectal Exam,
Breast Exam,
Hypertension Screening
As recommended
by physician
As recommended
by physician
Cancer screening paid at the highest level
Clinical Practice/
Guidelines
ICSI
Blue Cross
ICSI/Mandate
Blue Cross and
ICSI
Service Frequency Clinical Practice/
Guidelines
Colon Cancer Screening:
Occult Blood
Colon Cancer Screening:
Barium Enema,
Sigmoidoscopy,
Proctosigmoidoscopy
Colon Cancer Screening:
Colonoscopy
Cervical Cancer
Screening: Pap Smear
Breast Cancer Screening:
Conventional Film Screen
Mammography
1 per year ICSI/ACS
As recommended
by physician
As recommended
by physician
ICSI/ACS
ICSI/ACS
1 per year ICSI.ACS
1 per year ICSI.ACS
11-11

Coding Policies and Guidelines (Coding)
Preventive Care
Services (continued)
11-12
Service Frequency (does
not apply to Blue
Plus)
Prostate Cancer: Prostate
Specific Antigen (PSA)
Ovarian Cancer: CA125,
For those at high risk and
Trans-vaginal Ultrasound
Clinical Practice/
Guidelines
1 per year Blue Cross/
Mandate
1 per year Blue Cross/
Mandate
Services for consideration under the illness/medical level of
benefit
Any/all services that have an increased frequency due to an
effort to control or prevent abnormal condition from recurring
Procedures not considered preventive according to evidencebased
guidelines developed as clinical and industry standards;
for example, chest X-rays, urinalysis, complex lab and
diagnostic imaging procedures
Contraceptive management that is not part of Patient Protection
and Affordable Care Act (PPACA) women’s preventive
“contraceptive methods and counseling”
Eyewear including lenses, frames and contract lenses
Using the current version of the ICD-9-CM, report the patient’s
condition at the highest level of certainty that are related to the
services provided. Both the findings (if any exist) and the reason
for the visit should be reported.
Clinical practice guideline abbreviations include:
CDC/ACIP – Centers for Disease Control/Advisory
Committee on Immunization Practices
ICSI – Institute for Clinical Systems Improvement
ACS – American Cancer Society
Mandate – Mandated by Minnesota statute
Blue Cross – Blue Cross and Blue Shield of Minnesota and
Blue Plus
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (07/12/12)

Preventive Services
Required Under the
PPACA
Blue Cross Blue and Shield of Minnesota Provider Policy and Procedure Manual (07/12/12)
Coding Policies and Guidelines (Coding)
Effective for dates of service September 23, 2010 and after, the
Patient Protection and Affordable Care Act (PPACA) otherwise
known as health care reform (HCR), includes a provision for
preventive services at no cost to eligible subscribers. Blue Cross
has always considered preventive services an essential part of a
subscriber’s ongoing care and will continue to administer
preventive services in conjunction and in accordance with the
administrative and recommended guidelines under HCR:
United States Preventive Services Task Force (USPSTF)
ratings of A or B
Advisory Committee of Immunization Practices (ACIP), under
the Centers for Disease Control and Prevention (CDC)
Health Resources and Services Administration (HRSA)
Guidelines for Preventive Care and Screenings for Women,
Infants, Children and Adolescents
Blue Cross’ Preventive Care Services and Administrative
Guidelines already incorporated a majority of these
recommendations. As a result of PPACA, additional guidelines
have been included under Blue Cross’ preventive care services to
ensure compliance with the law. Please see the chart below for
more information on the additional services, recommendations and
suggested coding.
New Preventive
Service
Counseling
related to BRCA
screening
Interventions to
support breastfeeding
Health Care Reform
Recommendation
The USPSTF
recommends that
women whose family
history is associated
with an increased risk
for deleterious
mutations in BRCA1
or BRCA2 genes be
referred for genetic
counseling and
evaluation for BRCA
testing.
The USPSTF
recommends
interventions during
pregnancy and after
birth to promote and
support breastfeeding.
Suggested Codes
96040, 99401-99404,
and S0265 as
preventive with
V16.3, V16.41, V16.8
or V26.33
S9443 as preventive
with V24.1
11-13

Coding Policies and Guidelines (Coding)
Preventive services
required under the
PPACA (continued)
11-14
New Preventive
Service
Chemoprevention of
dental caries
Screening for
depression:
adolescents and adults
Recommendation for
counseling for a
healthy diet
Health Care Reform
Recommendation
The USPSTF
recommends that
primary care
clinicians administer
oral fluoride
supplementation at
currently
recommended doses
to preschool children
older than 6 months of
age whose primary
water source is
deficient in fluoride.
The USPSTF
recommends
screening adolescents
and adults for
depression when staffassisted
depression
care supports are in
place to assure
accurate diagnosis,
effective treatment
and follow-up.
The USPSTF
recommends intensive
behavioral dietary
counseling for adult
patients with
hyperlipidemia and
other known risk
factors for
cardiovascular and
diet-related chronic
disease. Intensive
counseling can be
delivered by primary
care clinicians or by
referral to other
specialists, such as
nutritionists or
dietitians.
Suggested Codes
D1206 (age 00-06)
99201-99205, 99211-
99215, 99384-99387
and 99394-99397,
G0438,G0439,G0444
as preventive with
V79.0
99401-99404, 99411-
99412, 99078, 97802-
97804, S9452, S9470
as preventive with
V65.3
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (07/12/12)

Preventive services
required under the
PPACA (continued)
New Preventive
Service
Screening and
counseling for
obesity: children and
adults
Recommendation for
counseling for tobacco
use
Recommendation for
counseling for tobacco
use in pregnant
women
Assess for alcohol and
drug use in
adolescents
Behavioral
assessments for
children
Testing for
tuberculosis in
children
Health Care Reform
Recommendation
The USPSTF
recommends that
clinicians screen all
children and adult
patients for obesity
and offer intensive
counseling and
behavioral
interventions to
promote sustained
weight loss for obese
adults.
The USPSTF
recommends that
clinicians ask all
adults about tobacco
use and provide
tobacco cessation
interventions for those
who use tobacco
products.
The USPSTF
recommends that
clinicians ask all
pregnant women
about tobacco use and
provide augmented,
pregnancy-tailored
counseling for those
who smoke.
HRSA recommends
alcohol and drug use
assessments for
adolescents
HRSA recommends
behavioral
assessments for
children of all ages
HRSA recommends
tuberculin testing for
children at higher risk
of tuberculosis
Blue Cross Blue and Shield of Minnesota Provider Policy and Procedure Manual (07/12/12)
Coding Policies and Guidelines (Coding)
Suggested Codes
97802-97804, 99078,
99401-99404, 99411-
99412, G0447, G0449
S9470 as preventive
with 278.00 or 278.01
99401-99404, 99406-
99407, 99411-99412,
G0436, G0437, S9453
as preventive with
305.1 or V15.82
99406-99407, G0436,
G0437, S9453 as
preventive with
649.00 or 649.03
G0442, G0443,
H0001, 99408-99409
as preventive with
V65.42 (age 11-20)
99420 as preventive
with V79.0, V79.1,
V79.2, V79.3, V79.8,
V79.9 (age 00-20)
86580 as preventive
with V74.1 (age 00-
20)
11-15

Coding Policies and Guidelines (Coding)
Preventive services
required under the
PPACA (continued)
11-16
Effective for plan years beginning on or after August 1, 2012,
PPACA requires certain items and services covered without cost–
sharing for women as recommended by the:
United States Preventive Services Task Force (USPSTF) ratings
of A or B
Advisory Committee of Immunization Practices (ACIP), under
the Centers for Disease Control and Prevention (CDC)
Health Resources and Services Administration (HRSA)
Guidelines for Preventive Care and Screenings for Women,
Infants, Children and Adolescents
To the extent not described in the USPSTF recommendations,
HRSA was charged with developing comprehensive guidelines for
preventive care and screenings for women. As part of this process,
HRSA commissioned an Institute of Medicine (IOM) report
entitled: “Clinical Preventive Services for Women: Closing the
Gaps”
1. Well–woman visit
2. Screening for gestational diabetes mellitus (GDM)
3. Counseling for sexually transmitted infection (STI)
4. Counseling and screening for human hmmunodeficiency virus
(HIV)
5. Counseling and screening for interpersonal and domestic
violence
6. Breastfeeding support, supplies and counseling
7. Human papillomavirus (HPV) testing
8. Contraceptive methods and counseling *
* Some employer group plans may be exempt or in temporary safe
harbor status for “contraceptive methods and counseling” and will
not have to offer women’s preventive “contraceptive methods and
counseling” until their plan year beginning on or after August 1,
2013. Temporary safe harbor does not apply to individual policies.
Non-preventive care received during a preventive care visit is
subject to normal plan cost sharing.
Please see the chart below for more information on the additional
services, recommendations and suggested coding.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (07/12/12)

New women’s
preventive service
Blue Cross coverage
Well-woman visit Well-woman preventive care visit
annually for adult women (ages 12 to
64) to obtain the recommended
preventive services that are age and
developmentally appropriate, which
may include preconception and
prenatal care as well as the list of
services in Table 5 – 6 “Clinical
Preventive Services for Women:
Closing the Gaps” July 2011 report
by the Institute of Medicine –
http://iom.edu/Reports/2011/Clinical
-Preventive-Services-for-Women-
Closing-the-Gaps.aspx
Screening for
gestational diabetes
mellitus (GDM)
Counseling for
sexually transmitted
infections (STI)
Based upon ICSI (Institute for
Clinical Systems Improvement)
GDM guideline below:
50 mg oral glucose load
followed one hour later by the
blood draw
If the one-hour (above)
glucose challenge test is
positive, a 100 g load
followed by a 3-hour glucose
tolerance test should be
performed
Note: Confirmation tests in the
2nd bullet (above) will be treated
as preventive ($0 member
liability)
Counseling on STIs, group or
individual sessions, once per year,
30-minute maximum per session for
women regardless of sexual activity
Counseling may be similar to the 5Ps
of the CDC: partners, prevention of
pregnancy, protection from STIs,
practices and past STIs
Blue Cross Blue and Shield of Minnesota Provider Policy and Procedure Manual (07/12/12)
Coding Policies and Guidelines (Coding)
Annual 99384-99386,
99394-99396 as
preventive with
V70.0 or V72.31
Gestational
diabetes screening
for pregnant
women at any
stage (week of
gestation) in the
pregnancy –
regardless of
presence of highrisk
factors such
as: ethnicity, BMI,
family history,
previous GDM,
patient has DM
82947, 82950,
82951, 83036 as
preventive with
any of the
following range:
V22.0-V22.2,
V23.0-V23.3,
V23.41, V23.42,
V23.49, V23.5,
V23.7, V23.81-
V23.87, V23.89 or
V23.9
Annual 99401, 99402,
99411, G0450 as
preventive with
V65.45 or V69.2
11-17

Coding Policies and Guidelines (Coding)
New women’s
preventive service
Counseling and
screening for human
immunodeficiency
virus (HIV)
Counseling and
screening for
interpersonal and
domestic violence
11-18
Blue Cross coverage
Counseling on HIV, group or
individual sessions, once per year,
30-minute maximum per session for
women regardless of sexual activity
Counseling up to individual
practitioner but may be similar to the
counseling for STI
Screening for HIV (already paid as
preventive by Blue Cross prior to
PPACA): lab tests to screen for HIV-
1 or HIV-2 antibodies
Screening up to each individual
practitioner: may be survey or
checklist, usually part of standard
intake/triage for office visit
Counseling – definition of
counseling up to each individual
practitioner, group or individual
sessions, no time limit per session,
but only one session per year
covered as preventive (even if
multiple sessions needed)
Counseling:
annual
Screening for STI:
as recommended
by a physician
Counseling:
G0445, G0450,
99401, 99402,
99411 as
preventive with
V65.44, V65.45 or
V69.2
Screening: 86701,
86703, 86689,
G0432, G0433,
G0435, 87390,
87534, 87535, as
preventive
Annual Screening: No
suggested coding.
No coding
available for
screening.
Counseling:
99401-99404, or
99411 or 99412 as
preventive with
V70.0 or V72.31
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (07/12/12)

New women’s
preventive service
Breastfeeding support,
supplies and
counseling
Human papillomavirus
(HPV) testing
Blue Cross coverage
Support: Per Institute of Medicine
(IOM) report: “Clinical Preventive
Services for Women: Closing the
Gaps” employer support of
breastfeeding such as allowing time
for mother to express milk at the
office and providing quiet and
private place to express and/or store
milk (mother’s room)
Supplies: Purchase, up to 100% of
allowed charges, of manual breast
pump from in-network supplier or
provider
Counseling: Trained provider to
ensure the successful initiation and
duration of breastfeeding. May be
provided as part of the hospital or
birthing center delivery stay.
Human papillomavirus DNA testing
in women with normal cytology
results, regardless of risk factors or
sexual activity
Blue Cross Blue and Shield of Minnesota Provider Policy and Procedure Manual (07/12/12)
Coding Policies and Guidelines (Coding)
Counseling: in
conjunction with
each pregnancy
Manual breast
pump: purchase
up to 6 months
post-partum
Screening should
begin at 30 years
of age and should
occur no more
frequently than
every three years
Support: No
suggested
coding. No
coding available
for support.
Supplies: E0602
Counseling:
S9443 as
preventive with
the following
V24.1,
V22.0-V22.2,
V23.0-V23.3,
V23.41,V23.42,
V23.49, V23.5,
V23.7, V23.81-
V23.87, V23.89
or V23.9
87620, 87621 as
preventive
11-19

Coding Policies and Guidelines (Coding)
New women’s
preventive service
Contraceptive methods
and counseling *
* Some employer
group plans may be
exempt or in
temporary safe harbor
status for
“contraceptive
methods and
counseling” and will
not have to offer
women’s preventive
“contraceptive
methods and
counseling” until their
plan year beginning on
or after August 1, 2013
11-20
Blue Cross coverage
Counseling: Counseling for women
ages 12 to 64 by trained personnel
regarding family planning;
distribution of information relating
to family planning, referral to
licensed physicians or local health
agencies for consultation,
examination, medical treatment,
genetic counseling, and prescriptions
for the purpose of family planning,
and the distribution of family
planning products, such as: charts,
thermometers, drugs, medical
preparations, and contraceptive
devices. Does not include the
performance, or referrals for
encouragement of voluntary
termination of pregnancy.
Inform any woman requesting
counseling on family planning
methods or procedures of:
1. Any methods or procedures
that may be followed (which
may include continuous
abstinence, natural family
planning/rhythm method),
including identification of
any that are experimental or
may post a health hazard to
the woman,
2. A description of any
attendant discomforts or
risks that might reasonably
be expected,
3. A fair explanation of likely
results, should a method fail,
4. A description of any benefits
that might reasonably be
expected of any method,
5. A disclosure of appropriate
alternative methods or
procedures,
6. An offer to answer any
inquiries concerning
Counseling:
once/year
Methods: Select
oral
contraceptives,
supplies and
procedures will be
covered
Counseling:
99384-99386
99394-99396,
S0610, S0612 or
S0613 as
preventive with
V25.01-V25.04,
V25.09, V25.41,
V25.43 or V25.49
Methods: Varies
depending upon
covered drug,
supply or
procedure
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (07/12/12)

New women’s
preventive service
Contraceptive methods
and counseling *
* Some employer
group plans may be
exempt or in
temporary safe harbor
status for
“contraceptive
methods and
counseling” and will
not have to offer
women’s preventive
“contraceptive
methods and
counseling” until their
plan year beginning on
or after August 1, 2013
(continued)
Preventive Services
Required Under the
PPACA (continued)
Blue Cross coverage
An instruction that the person is free
either to decline commencement of
any method or procedure or to
withdraw consent to a method or
procedure at any reasonable time
Methods:
For women ages 12 to 64; limited to
specific oral contraceptives, supplies
and procedures. Coverage may vary
by group and pharmacy benefit
manager (PBM) and is subject to
change if covered formulary
changes. Members should contact
customer service at the number on
the back of their member ID card for
the specific methods covered by their
group or policy.
Blue Cross Blue and Shield of Minnesota Provider Policy and Procedure Manual (07/12/12)
Coding Policies and Guidelines (Coding)
Not all health plans, policies or employer groups will define or
administer the women’s preventive coverage in the same way.
PPACA requires coverage of the women’s preventive items for
non-grandfathered status plans. Blue Cross made a business
decision to apply the women’s preventive benefits to plans that
accepted the prior PPACA preventive care package (dates of
service September 23, 2010 and after) – some of those groups may
be grandfathered status. Also, self–insured groups may offer a
different, or richer, benefit. Groups may have different drugs
covered for “contraceptive methods and counseling” depending
upon the pharmacy benefit manager (PBM) they use. Members
should verify their preventive coverage before receiving benefits by
calling the customer service phone number on the back of their
member identification (ID) card.
11-21

Coding Policies and Guidelines (Coding)
General Guides Submit the code that most accurately identifies the service(s)
performed. Documentation in the patient’s medical record must
support the codes submitted.
11-22
Do not use multiple codes when services can be represented by
a single code, unless otherwise instructed. Fragmented services
(reporting several codes when one adequately defines the
service) will be subject to our coding software edits and may
be denied.
Unlisted codes should only be used if no code exists to
describe the service or supply. HCPCS codes for unlisted
services require a complete narrative description.
Submit all services for the same date of service on the same
claim.
“C” HCPCS codes.
Codes C1000-C9999 are for items classified in newtechnology
ambulatory payment classifications (APCs)
under the outpatient prospective payment systems. These
codes are exclusively for use in billing for institutional
transitional pass-through payments. Blue Cross does not
use an APC methodology for adjudication or payment of
claims, thus C codes will not be used in adjudication.
Processing and payment will be determined by other
factors on the claim, such as a revenue code.
It is the intention of CMS to allow the use of the codes by
all payers regardless of payment methodology, so C
HCPCS codes will be accepted on institutional (UB-04 or
837I) claims only. However, C codes submitted on a
professional claim (CMS HICF/837P), other than
freestanding ambulatory surgical centers (ASC), will deny
as provider liability.
Free-standing ASC services are submitted on a professional
claim format. C-codes may be submitted, as appropriate, on
freestanding ASC claims.
Zero-billing Blue Cross will allow zero-billing or no-charge claim lines.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (07/12/12)

Coding Edits
Blue Cross Blue and Shield of Minnesota Provider Policy and Procedure Manual (07/12/12)
Coding Policies and Guidelines (Coding)
Overview Blue Cross uses an automated procedure editing tool. This tool has
been adopted and modified by Blue Cross to assist in a consistent
and fair claim review process. The procedure code edits may also
reflect Blue Cross’ Medical Coverage Guidelines, benefit plans
and other Blue Cross policies. Unbundling, fragmentation,
mutually exclusive procedures, duplicate, obsolete or invalid codes
are all identified through the use of this coding edit application.
The procedure code edits are based on CPT guidelines, a review of
the Center for Medicare and Medicaid Services (CMS) Correct
Coding Initiative policies and guidelines, specialty society
guidelines, agreed upon industry practices and analysis by an
extensive clinical consultant network. This automated review
process is designed to apply the same industry criteria consistently
across all professional claims.
Edit Descriptions Procedure Code Unbundling/Replacement
Procedure code unbundling is the submission of multiple
procedure codes for a group of specific procedures that are
components of a single comprehensive code. Procedure
unbundling may occur in one of two ways:
A professional claim could be submitted that has procedure codes
for both the individual components, and the procedure code for the
comprehensive procedure. Blue Cross would rebundle the
individual component codes into the comprehensive procedure
code for payment.
Procedure unbundling could also occur when a professional claim
is submitted with only the individual components of the
comprehensive code. In this situation, the software will recognize
the relationship between the comprehensive code and its individual
components. Then, it will automatically add the comprehensive
code to the claim and rebundle the individual components into that
comprehensive code for payment.
11-23

Coding Policies and Guidelines (Coding)
Edit Descriptions
(continued)
11-24
An example would be billing the following procedure codes
together:
33207......Insertion of heart pacemaker, ventricular
33208......Insertion of heart pacemaker, atrial and ventricular
Procedure 33208 is identified as the primary procedure code. CPT
33207 would be rebundled because it is an integral part of
procedure 33208. Rather than a line item denial, the procedure and
related charge will be summed together and a new allowance for
the surviving code will be established based on your contracted fee
schedule.
Another example would be billing the following procedure codes
together:
82374......Carbon dioxide
82435......Chloride
84132......Potassium
84295......Sodium
In combination, the four codes above would be rebundled and
replaced with the more appropriate procedure 80051-electrolyte
panel. Related charges will be summed together and the allowance
based on the comprehensive code 80051.
When this edit is applicable, the following message will appear on
your current remittance advice:
This service is a component of a procedure that has already
been processed on this or another claim.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (07/12/12)

Mutually Exclusive
Procedures
Blue Cross Blue and Shield of Minnesota Provider Policy and Procedure Manual (07/12/12)
Coding Policies and Guidelines (Coding)
Mutually exclusive procedures exist when a claim is submitted for
two or more procedures that are not usually performed on the same
patient, on the same date of service. In mutually exclusive
relationships, the most clinically intense code is recognized for
payment. Clinical intensity is generally based on the total RVU for
the procedures submitted.
An example would be billing the following procedure codes
together:
58260......Vaginal Hysterectomy
58150......Total Abdominal Hysterectomy
Since a hysterectomy would not be performed using two different
approaches, the vaginal hysterectomy would be denied as mutually
exclusive to the abdominal hysterectomy. This edit would result in
the line item denial of procedure 58260 and would be the
participating network provider’s liability.
Another example would be billing the following procedures
together:
27550......Closed treatment of a knee dislocation
27556......Open treatment of a knee dislocation
The knee would not be reduced by doing both procedures. The
open procedure would survive as the one that was more clinically
intense. This would result in the line item denial of procedure
27550 and would be the participating network provider’s liability.
When this edit is applicable, the following message(s) will appear
on your current remittance advice:
Payment is included in the allowance of the other procedure.
Service is not payable with other service rendered on the same
date.
These charges are not covered. Less complex procedures with
the same outcome and date of service as another procedure are
not eligible.
11-25

Coding Policies and Guidelines (Coding)
Incidental Procedures Incidental is defined as a procedure carried out at the same time as
a primary procedure, but is clinically integral to the performance
of the primary procedure, and therefore, should not be reimbursed
separately.
11-26
An example would be billing the following procedure codes
together:
59300 .....Episiotomy
59409 .....Vaginal delivery
An episiotomy performed as part of the overall management of a
delivery does not warrant a separate identification. This would
result in the line item denial of procedure 59300 and would be the
participating network provider’s responsibility.
Another example would be billing the following procedure codes
together:
44005 .....Enterolysis (lysis of adhesions, separate procedure)
44140 .....Partial colectomy with anastomosis
Services that are identified by CPT with the term “separate
procedure” are commonly carried out as an integral component of
a total service. Separate procedures are not reported in addition to
the total procedure or service of which it is considered an integral
component. This would result in the line item denial of procedure
44005 and would be the participating network provider’s liability.
When this edit is applicable, the following message(s) will appear
on your current remittance advice:
This procedure is incidental to another procedure processed
on this or another claim.
This procedure is incidental to the primary procedure.
Reimbursement is included in the allowance for that primary
procedure.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (07/12/12)

Medical Visits on the
Same Day as Surgery
Blue Cross Blue and Shield of Minnesota Provider Policy and Procedure Manual (07/12/12)
Coding Policies and Guidelines (Coding)
In keeping with the CPT surgical “package,” related E/M services
are not reimbursed separately when submitted with a procedure
performed on the same day. Modifiers may be used with E/M
services that are not considered part of the same day surgical
package. Please refer to the current year’s CPT manual for E/M
services and surgery guidelines.
Some of the related CPT modifiers would include:
-24 unrelated E/M service by the same physician during a
postoperative period
-25 significant, separately identifiable E/M service by the same
physician on the day of a procedure or other service
The provider should add these modifiers when a patient’s
condition requires a significant, separately identifiable service
above and beyond the usual care associated with the procedure.
Documentation in your files must support the use of modifier –25
with E/M codes as defined in CPT. Use modifier –25 with newpatient
and established-patient E/M codes to prevent denial of
significant, separately identifiable E/M services performed on the
same day as a procedure or other service. Some of these other
services are allergy injections, joint injections, chemotherapy
administration, brachytherapy services and dialysis. Modifier –25
is not required by Blue Cross with consultation and emergency
room codes.
One of the following messages will appear on your current
remittance advice:
Payment is included in the allowance for another
service/procedure
Based on the other services submitted for this service date,
reimbursement is not considered for this medical visit.
Note: Requests to add a modifier -24 or -25 to a denied service
must follow the appeal process. An adjustment request will
not be allowed.
11-27

Coding Policies and Guidelines (Coding)
Global Surgical
Package – Pre- and
Postoperative Services
11-28
As defined by CPT, the surgical “package” includes the surgical
operation, local infiltration, metacarpal/digital block or topical
anesthesia when used, and the normal, uncomplicated follow-up
care visits. These services, when billed in addition to surgery, are
denied as included in the surgical allowance. The surgical package
includes all normal and uncomplicated care including pre- and
postoperative visits as part of the reimbursement for the surgical
procedure. Preoperative visits are defined as visits by the surgeon
or another practitioner in the same practice on the day of a surgery
for minor procedures and the day before or day of major surgical
procedures.
We do not consider new patient codes exceptions to the package.
The fact that the patient is new is not reason alone to exclude the
visits from the global package. Blue Cross follows the same
postoperative time frames associated with surgical procedures as
Medicare of 10 or 90 days. These can be found in the Federal
Register. Routine postoperative medical visits rendered with this
time frame and related to the surgery will not be recognized for
separate reimbursement as an unbundled component of the total
surgical package.
One of the following messages will appear on your current
remittance advice:
This procedure is within the postoperative range for a surgery
found on this or another claim.
This procedure is within the preoperative range for a surgery
found on this or another claim.
Pre- and postoperative care is a covered benefit and these
services are included in the allowance
Modifiers -55 and -56
For Blue Cross, modifiers –55 and –56 for pre- and postoperative
care are used with surgery codes.
Modifier –57
Modifier –57 is used to indicate that the E/M service resulted in
the initial decision to perform surgery either the day before a major
surgery (90 day global) or the day of a major procedure.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (07/12/12)

Units of Service
Validation and
Restriction
Blue Cross Blue and Shield of Minnesota Provider Policy and Procedure Manual (07/12/12)
Coding Policies and Guidelines (Coding)
Blue Cross edits procedure code units on professional claims
(837P/1500 HICF).
While each service must be submitted with a unit of measurement,
multiple units of service per code, per date of service are only
applicable if the code definition supports submission of more than
one unit. This is usually indicated by words such as each or per.
Additionally, the number of units for codes that qualify for
submission of multiple units may be subject to limits. Although
Blue Cross is not following Medicare’s Medically Unlikely Edits
(MUE), the editing logic is similar to MUEs.
This edit will occur in the pre-adjudication phase of processing. If
the claim submission does not pass (or fails for greater than one
unit per day) it will stop and be rejected back to the provider.
This rejection occurs before the submission is accepted as a claim,
therefore a claim number is not assigned and the provider must
correct the data and resubmit all charges. There will not be any
duplicate editing or adjustments because a “claim” was not created
in the payer adjudication system.
The error denial message will be:
2045 -- Unit(s) billed is inconsistent with procedure code.
Please correct the claim and resubmit.
11-29

Coding Policies and Guidelines (Coding)
General Claims
Processing
Information
Medical and Surgical
Supplies
Multiple Surgery
Guidelines
11-30
Scope Procedures
Our coding software makes the following assumptions when
determining payment for multiple scope procedures billed on the
same date of service:
A diagnostic scope is always incidental to a surgical scope.
A diagnostic scope with biopsy is always incidental to a
surgical scope.
A diagnostic scope with or without biopsy is always incidental
to an open surgical procedure in the same area.
A diagnostic scope rebundles to a diagnostic scope with biopsy
unless the code description makes the distinction with biopsy
vs. without biopsy.
CPT descriptions such as: complete vs. partial, with vs.
without, complex vs. simple, etc. means there are two mutually
exclusive codes for the procedures.
Medical and surgical supplies during an outpatient or physician
office visit are included as incidental to the E/M service or
procedure performed, and will not be separately reimbursed.
Multiple surgical procedures performed during the same operative
session are processed in accordance with Blue Cross multiple
surgical guidelines. These guidelines state the primary procedure is
determined as the highest billed charge and is reimbursed at 100%
of the fee schedule or billed amount, whichever is less. Secondary,
tertiary procedures, etc., again determined in order of billed
charge, are reimbursed at 50% of the fee schedule or billed
amount, whichever is less, regardless of separate site or incision.
In addition, procedures noted in CPT as “modifier –51 exempt” are
not subject to multiple surgery reductions.
Patient Billing Impact The patient is not responsible and must not be balance billed for
any procedures for which payment has been denied or reduced by
Blue Cross as the result of a coding edit. Edit denials are designed
to ensure appropriate coding and to assist in processing claims
accurately and consistently.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (07/12/12)

Blue Cross Blue and Shield of Minnesota Provider Policy and Procedure Manual (07/12/12)
Coding Policies and Guidelines (Coding)
Coding Appeals Blue Cross’ coding edits are updated at minimum annually, to
incorporate new codes, code definition changes and edit rule
changes. All claims submitted after the implementation date of this
update, regardless of service date, will be processed according to
the updated version. Where Medicare’s CCI (Correct Coding
Initiative) edits are identical, we will consider the appeal with
additional documentation, but the issue may be upheld. No
retrospective payment changes, adjustments, and/or request
refunds will be made when processing changes are a result of new
code editing rules due to a software version update. Notice of this
update will be published in the Provider Press or Provider Bulletin,
with a ‘Summary of Change’ summarizing new edits.
Blue Cross has adopted a standard process to review edit appeals
and providers have the right to appeal with additional information.
If you have a question or appeal about our policy regarding a
particular coding combination, provide a written statement of the
concern, along with the following information and/or
documentation normally required for a medical review.
Written explanation supporting the procedures submitted, e.g.,
specific references, specialty specific criteria
Documentation from a recognized authoritative source that
supports your position on the procedure codes submitted
Once received, the inquiry or appeal will be reviewed and if
necessary, forwarded to the medical review department for
determination. The review may result in approval or denial of the
claim, based on review of the information submitted.
Note: Requests to add modifier -24, -25 or -59 to a denied service
must follow the appeal process. An adjustment request will
not allowed.
Refer to Chapter 10 for additional information regarding
submission of appeals.
11-31

Coding Policies and Guidelines (Coding)
Helpful Coding Tips We recognize the challenges you have in staying up-to-date with
coding changes. Below are some helpful tips to assist with
accurate and effective coding to support correct claim processing
and reimbursement.
Coding Immunizations
and Injections
11-32
Code using current coding books. Order new CPT and HCPCS
manuals every year, as codes are added, deleted and revised
annually. Submitting invalid or deleted codes will result in claim
rejection or denials. Web links to review for possible updates:
http://www.ama-assn.org/ama/pub/category/3884.html
http://www.cms.hhs.gov/HCPCSReleaseCodeSets/
http://www.cms.hhs.gov/MLNProducts/
http://www.health.state.mn.us/auc/guides.htm
It is appropriate when administering an immunization or injection
to bill administration codes (90460-90461, 90471-90474, 96372-
96375, G0008-G0010). Reimbursement for vaccines/toxoids and
immunization administration is currently allowed in addition to
preventive medicine services (99381-99384, 99391-99394, 99401-
99404) and newborn care services (99460-99463).
Immunizations
If only an immunization is administered, bill the CPT code for the
vaccine/toxoid administered and the applicable CPT administration
code (90460-90474).
Example: A 65-year old patient comes to your office just for a flu
vaccine. Bill the vaccine code 90658 and vaccine administration
code 90471.
Immunizations and E/M Visits
E/M codes 99201-99205 and 99212-99215 are eligible for separate
reimbursement when billed on the same date of service as
vaccine/toxoid codes 90476-90749 and the immunization
administration codes 90461-90461.
Example:
A one-year-old established patient has a preventive visit and a
polio vaccine. Bill the appropriate preventive visit CPT code
(i.e., 99392), the polio vaccine (i.e., 90712) and in this case,
the oral administration code (90473).
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (07/12/12)

Chapter 11
Coding Policies and Guidelines
(Copays)
Table of Contents
Office Call Copays...............................................................................................................11-2
Blue Cross Blue Shield of Minnesota Provider Policy and Procedure Manual (11/12/10) 11-1

Coding Policies and Guidelines (Copays)
Office Call Copays Following is a listing of procedure codes to which the office call
copay may apply when included in the contract benefits. This is not
an all-inclusive list.
11-2
Code Description
90804-90815 Psychotherapy
90847, 90853 Family therapy/ Group therapy
92002-92014 Ophthalm ological services (new or established
patient)
92597 Evaluation for use/fitting of voice prosthetic
device
92605,
92607-92608
Evaluation for prescription of speech/ non-speech
generating device
97001-97004 Physical and occupational evaluations and
reevaluations
98925-98929 Office or outpatient visit with osteopathic
manipulative therapy
98940-98943 Chiropractic visit with manipulation/adjustment
99201-99215 Office or other outpatient services, new and
established patient
99218-99220 Initial observation care
99241-99245 Consultations (office, outpatient) new or
established patient- Based on place of service
99354-99357 Prolonged physician services
99381-99387 Preventive medicine, new patient
99391-99397 Preventive medicine, established patient
99401-99404 Preventive medicine individual counseling
99406-99409 Behavior change interventions
99411-99412 Preventive medicine group counseling
99420, 99429 Other preventive medicine services
G0245-G0246 E/M of a diabetic patient
H1000, H1001,
H1003
Prenatal risk assessment, high risk antepartum
care, nutrition education
S9401 Anticoagulation clinic, inclusive of all services
except laboratory tests, per session
Blue Cross Blue Shield of Minnesota Provider Policy and Procedure Manual (11/12/10)

Chapter 11
Coding Policies and Guidelines
(Modifiers)
Table of Contents
Modifiers..............................................................................................................................11-2
Anatomical Modifiers ........................................................................................................11-16
Modifiers Defined by DHS................................................................................................11-17
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (10/05/11) 11-1

Coding Policies and Guidelines (Modifiers)
Modifiers General Guidelines
11-2
Modifiers are two-digit codes that are appended to a service as a
means to indicate that the service/procedure is affected or altered
by a specific circumstance and to add specificity, but not changed
in its definition.
Modifiers are found in both CPT and HCPCS manuals. CPT
modifiers can be found in Appendix A. Genetic Testing Code
Modifiers are found in Appendix I of CPT. A complete list of
HCPCS modifiers is found as an appendix to the HCPCS manual.
CPT codes are not limited to CPT modifiers. HCPCS codes are not
limited to HCPCS modifiers. HCPCS modifiers may also be used
with CPT codes and/or in combination with CPT modifiers. CPT
modifiers may also be used with HCPCS codes and/or in
combination with HCPCS modifiers. For example, -TC and –76
can be appended to a radiology procedure to indicate the technical
component of the services was repeated.
Modifiers may be used to indicate:
A service or procedure has both a professional and technical
component.
A service or procedure was performed by more than one
physician and/or in more than one location.
A service or procedure has been increased or reduced.
Only part of a service was performed.
A bilateral procedure was performed.
A service or procedure was provided more than once.
Unusual events occurred.
A DME item is purchased or rented.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (10/05/11)

Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (10/05/11)
Coding Policies and Guidelines (Modifiers)
Modifiers (continued) It is important to append all appropriate modifiers the first time the
claim is submitted.
Modifiers are also subject to compatibility edits with the procedure
to which they are appended. For example, an Evaluation and
Management (E/M) service appended with a -59 modifier will be
denied.
Note: If your claim is denied due to lack of documentation to
support the use of a specific modifier or an invalid
modifier/procedure combination, you may submit a claim
payment appeal or replacement claim. Your appeal must be
in writing and accompanied by the necessary
documentation. Replacement claims must include an
attachment with supporting documentation.
The information outlined below is a general guideline regarding
the use of modifiers. The list is not all-inclusive. Refer to your
CPT and HCPCS for a complete list of modifiers. When a specific
service/circumstance requires the use of a modifier, the submission
criteria is outlined in the applicable specialty section of the Coding
Chapter of the Blue Cross Provider Policy and Procedure Manual.
11-3

Coding Policies and Guidelines (Modifiers)
11-4
**The impact to payment statements below are a general guide
and not a guarantee of payment**
MOD Description Submission Guidelines Impact to Payment
-22 Increased
Procedural
Services
-24 Unrelated
Evaluation and
Management
(E/M) Service by
the Same
Physician During
a Post-operative
Period.
Note: Blue Cross
defines the
“same
physician” as the
same physician,
or physicians of
the same or
similar specialty
within the same
clinical practice.
Requires submission of an operative
report, narrative and/or other relevant
documentation that adequately describes
what care/service was greater than usually
required.
Do not use modifier –22 when there is an
existing code to describe the service.
By appending the –24 modifier to an
unrelated E/M service you are indicating
that the patient’s condition requires a
significant, separately identifiable E/M
service above and beyond the other service
provided, or beyond the usual preoperative
and post-operative care
associated with the procedure that was
performed. Services appended with a –24
modifier must be sufficiently documented
in the patient’s medical record that the visit
was unrelated to the post-operative care of
the procedure. An ICD-9-CM that clearly
indicates that the reason for the encounter
was different and unrelated to the postoperative
care may provide sufficient
documentation.
Note: Requests to add a modifier -24 to a
denied service must follow the
replacement claim process. An
adjustment request will not be
allowed.
The availability of
additional payment
will be determined
based on review of
supporting
documentation.
Separate payment of
the E/M may be
allowed.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (10/05/11)

Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (10/05/11)
Coding Policies and Guidelines (Modifiers)
MOD Description Submission Guidelines Impact to Payment
-25 Significant
Separately
Identifiable
Evaluation and
Management
(E/M) Service by
the Same
Physician on the
Same Day of the
Procedure or
Other Service
-26 Professional
Component
-50 Bilateral
Procedure
Use the –25 modifier when an E/M service
is rendered on the same day as a minor
surgical procedure (0 or 10 day global
period).
The use of –25 is appropriate only when
the E/M service provided is above and
beyond the usual pre and post-operative
service associated with a procedure.
No documentation needs to be submitted
with the initial claim. However, E/M
services submitted with a –25 modifier are
subject to review. Furthermore, medical
documentation, when requested, needs to
support the significant, separately
identifiable E/M service.
Note: Requests to add a modifier -25 to a
denied service must follow the
replacement claim process. An
adjustment request will not be
allowed.
Certain procedures are a combination of a
physician component and a technical
component. When the physician
component is reported separately, the
service may be identified by adding the
modifier ‘26’ to the usual procedure
number.
The professional component applies to the
physician who interprets the procedure and
provides a written report.
Surgical procedures performed on bilateral
pieces of anatomy should be billed on one
line. The –50 modifier should be appended
to the submitted lines of service.
Blue Cross adheres to CMS’ published list
of bilateral procedures
Separate payment of
the E/M may be
allowed.
Payment is made
based on the
professional portion
of the RVU
associated with the
service.
Payment is made at
150% of the allowed
amount for the
procedure.
11-5

Coding Policies and Guidelines (Modifiers)
MOD Description Submission Guidelines Impact to Payment
-51 Multiple
Procedures
-52 Reduced
Services
-53 Discontinued
Procedure
11-6
When more than one service is performed
during the same operative session, the –51
modifier may be appended to all secondary
surgical procedures.
It is not necessary to append the –51
modifier to “add on” or to exempt codes.
Applicable code edits will be applied to
services submitted.
Append the –52 modifier to indicate that a
service or procedure is partially reduced or
eliminated at the physician’s discretion.
This provides a means of reporting reduced
services without disturbing the
identification of the basic service.
Append –53 when the physician elects to
terminate the procedure
The -51 modifier
itself does not affect
payment. Multiple
surgical payment is
based on whether the
surgical procedure
may be subject to a
multiple surgery.
Then the reduction
would be based on the
allowed amount. The
lowest valued
procedure(s) will
have the multiple
surgical reduction
applied. When
covered, payment is
made at 50% of the
allowed amount for
all allowable
secondary procedures.
The normal full
charge billed or a
reduced charge for the
procedure may be
submitted. Blue Cross
will pay the lesser of
either 90% of the
physician fee
schedule allowance
for the procedure or
the charge submitted.
The normal full
charge or reduced
charge should be
submitted.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (10/05/11)

Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (10/05/11)
Coding Policies and Guidelines (Modifiers)
MOD Description Submission Guidelines Impact to Payment
-54 Surgical Care
Only
-55 Post-operative
Management
Only
-56 Pre-operative
Management
Only
Append –54 when one physician performs
intraoperative portion of a surgical
procedure while another practitioner(s)
from a different practice provides preoperative
and/or post-operative
management.
Surgery should be billed globally (no
modifier) if the pre-, intra-, and postoperative
services are rendered by the
same provider or other practitioners who
are employed by the same clinic (same tax
ID number).
Append –55 to the surgical procedure code
only when post-operative is provided by a
different clinic than performed the surgery.
Append the –55 to the surgical procedure
code.
Append –56 to the surgical procedure code
only when pre-operative is provided by a
different clinic than performed the surgery.
Append the –56 to the surgical procedure
code.
Payment is made at
90% of the allowed
amount.
Separate payment
may be allowed.
Services will be
denied if the –55
modifier is billed by a
practitioner who is
employed by the same
clinic (same tax
ID number) as the
surgeon.
Separate payment
may be allowed.
Services will be
denied if the –56
modifier is billed by a
practitioner who is
employed by the same
clinic (same tax ID
number) as the
surgeon.
11-7

Coding Policies and Guidelines (Modifiers)
MOD Description Submission Guidelines Impact to Payment
-57 Decision for
Surgery
11-8
The –57 modifier is appended to indicate
that the E/M service resulted in the initial
decision to perform surgery either the day
before or the day of a major surgical
procedure (90-day global period).
Do not append this modifier when a minor
surgical procedure (0-, 10-day global
period) is performed.
The –57 should not be used to report an
E/M service that was pre-planned or prescheduled
the day before or the day of
surgery, as they would be included as part
of the global surgical package. Patients are
normally reevaluated on the date of the
actual surgery to assure the service can be
performed. That clearance would be
included in the global period and should
not be reported separately.
Note: Requests to add a modifier -57 to a
denied service must follow the
replacement claim process. An
adjustment request will not be
allowed.
Modifer-57 may not
affect edits or
payment. However, if
applicable, the
modifier should be
appended to the E/M.
Services denied may
be considered on
subsequent appeal.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (10/05/11)

Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (10/05/11)
Coding Policies and Guidelines (Modifiers)
MOD Description Submission Guidelines Impact to Payment
-59 Distinct
Procedural
Service
Modifier –59 may be appended to identify
non-E/M procedures/services that are not
normally reported together, but are
appropriate under the circumstances.
However, when another already
established modifier is appropriate it
should be used rather than modifier –59.
Only if no more descriptive modifier is
available, and the use of modifier –59 best
explains the circumstances, should
modifier –59 be used. Modifier –59 is
always appended to the component or
lesser procedure code. Documentation
supporting the separate and distinct status
must be present in the patient’s medical
record.
A -59 modifier may be appropriate to
indicate a:
Different session
Different procedure
Different anatomical site or organ
system
Separate lesion
Separate incision or excision
Separate injury
Note: Requests to add a modifier -59 to a
denied service must follow the
replacement claim process. An
adjustment request will not be
allowed.
-62 Two Surgeons The use of this modifier is appropriate to
identify the use of two primary surgeons
when required during a surgical procedure.
Documentation should be submitted to
support the use of the –62 modifier.
Modifer-59 may not
affect edits or
payment. However, if
applicable, the
modifier should be
appended to the
service. Generally,
the –59 modifier is
only applicable to
those code
combinations noted in
the Correct Coding
Initiative (CCI) code
list with a modifier
indicator of “1” which
specifies the services
are distinct and
separate and thus
allowed. Service
denied may be
considered on
subsequent appeal.
Payment will be
determined based on
the Medicare
Physician Fee
Schedule Database
(MPFSDB) indicators
1 or 2 and based on
Medical Review of
supporting
documentation.
11-9

Coding Policies and Guidelines (Modifiers)
MOD Description Submission Guidelines Impact to Payment
-66 Surgical Team The use of this modifier is appropriate to
identify the services of a physician
involved as part of a surgical team. Under
some circumstances, highly complex
procedures (requiring the concomitant
services of several physicians, often of
different specialties) are carried out under
the “surgical team” concept.
-73 Discontinued
out-patient
hospital/
ambulatory
surgery center
(ASC) procedure
prior to the
administration of
anesthesia
-76 Repeat
Procedure or
Service by Same
Physician
11-10
Due to extenuating circumstances or those
that threaten the well being of the patient,
the physician may cancel a surgical or
diagnostic procedure subsequent to the
patient's surgical preparation, but prior to
the administration of anesthesia. Under
these circumstances, the intended service
that is prepared for but cancelled can be
reported by its usual procedure number and
the addition of the modifier -73.
The practitioner may need to indicate that a
procedure or service was repeated
subsequent to the original procedure or
service on the same day. This circumstance
may be reported by adding modifier –76 to
the repeated procedure/service.
Note: In situations warranting the use of
both the –26 and –76 modifier (e.g.,
reading multiple chest X-rays of a patient
performed on the same day), submit the –
26 modifier in the first position with the
initial procedure and the –76 in the first
position for the repeat procedure.
Payment will be
determined based on a
case-by-case basis
and review of
supporting
documentation.
Payment is made at
50% of the allowed
amount.
Effective for claims
processed on and after
January 1, 2012.
Separate payment of
the service may be
made.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (10/05/11)

Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (10/05/11)
Coding Policies and Guidelines (Modifiers)
MOD Description Submission Guidelines Impact to Payment
-77 Repeat
Procedure by
Another
Physician
-79 Unrelated
Procedure or
Service by the
Same Physician
During Postoperative
Period
-80 Assistant
Surgeon
-81 Minimum
Assistant
Surgeon
-82 Assistant
Surgeon (When
Qualified
Resident
Surgeon Not
Available)
The practitioner may need to indicate that a
procedure or service was repeated
subsequent to the original procedure or
service on the same day. This circumstance
may be reported by adding modifier –77 to
the repeated procedure/service.
Note: In situations warranting the use of
both the –26 and –77 modifier (e.g.,
reading multiple chest X-rays of a
patient performed on the same day),
submit the –26 modifier in the first
position with the initial procedure
and the –77 in the first position for
the repeat procedure.
Append this modifier to
procedures/services performed during the
post-operative period of another procedure,
if the procedure/service is unrelated to the
original procedure.
Append this modifier to surgical assists
performed by a physician, nurse
practitioner, physician assistant, or RNFA.
Blue Cross adheres to CMS’ published list
of services eligible for surgical assist.
Append this modifier to surgical assists
performed by a physician, nurse
practitioner, physician assistant, or RNFA.
Blue Cross adheres to CMS’ published list
of services eligible for surgical assist.
Append this modifier to surgical assists
performed by a physician, nurse
practitioner, physician assistant, or RNFA.
Blue Cross adheres to CMS’ published list
of services eligible for surgical assist.
Separate payment of
the service may be
made.
Separate payment of
the service may be
made.
Payment is made at
16% of the allowed
amount.
Multiple surgery
pricing logic also
applies to assistant at
surgery services.
Payment is made at
16% of the allowed
amount.
Multiple surgery
pricing logic also
applies to assistant at
surgery services.
Payment is made at
16% of the allowed
amount.
Multiple surgery
pricing logic also
applies to assistant at
surgery services.
11-11

Coding Policies and Guidelines (Modifiers)
MOD Description Submission Guidelines Impact to Payment
-90 Reference
(outside) Lab
-91 Repeat Clinical
Diagnostic Lab
Test
-99 Multiple
Modifiers
-AA Anesthesia
services
performed
personally by
anesthesiologist
-AD Medical
supervision by a
physician; more
than four
concurrent
anesthesia
procedures
-AS PA, Nurse
Practitioner, or
Clinical Nurse
Specialist
Services for
Assistant at
Surgery
11-12
The use of the –90 modifier is appropriate
when a lab provider, not the treating
physician, performs a laboratory
procedure. The –90 modifier should be
appended to the procedure code/test that
was sent to the lab.
Append the modifier to a lab procedure
that was repeated during the day.
Modifier -99 indicates that multiple
modifiers may apply to a particular service.
Because Blue Cross can accept up to four
modifiers, -99 should be used only if there
are five or more modifiers applicable to a
particular service line. In that
circumstance, if -99 is submitted, the
additional modifiers must be entered on the
narrative record.
Append the modifier when the
anesthesiologist is physically present in the
operating room, personally performs the
induction and emergence, and directly
monitors the patient throughout the entire
operative procedure.
Append the modifier when the
anesthesiologist supervises more than four
concurrent anesthesia procedures. The
anesthesiologist may perform the induction
and emergence but may not be present
during the entire operative session.
Append this modifier to surgical assists
performed by a physician assistant, nurse
practitioner, or clinical nurse specialist.
The modifier does not
impact payment for
the lab test; however,
it may be used in
determining whether
payment will be made
for more than one
type of specimen
collection.
Separate payment of
the service may be
made.
Impact of payment or
adjudication may be
based on what the
additional modifier(s)
represents.
Payment is made at
the full-time
anesthesia conversion
rate.
Payment is made at
the part-time
anesthesia conversion
rate.
Payment is made at
16% of the allowed
amount.
Multiple surgery
pricing logic also
applies to assistant as
surgery services.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (10/05/11)

Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (10/05/11)
Coding Policies and Guidelines (Modifiers)
MOD Description Submission Guidelines Impact to Payment
-GA Waiver of
liability
statement on file
The GA modifier (WAIVER OF
LIABILITY STATEMENT ON FILE)
may be submitted when the patient has
signed a waiver specifically for a service
that may not be covered. If the service is
denied, the payment for that service is the
patient’s liability in most cases.
General rules surrounding GA:
1. GA is an acceptable modifier.
Providers may submit this modifier if a
waiver is signed by the patient and is
on file with the provider. The waiver
must be for the specific service and
date only – blanket waivers are not
acceptable.
2. Liability will not be changed under
some circumstances: Denial waiting for
additional information, duplicate
billing, incidental or included in the
basic service rendered denials, and
denials generated from a coding
software decision (such as incidental,
mutually exclusive or visit logic).
These denials will always remain
provider liability regardless if the GA
is submitted.
3. If the service denies provider liability,
the provider may ask for an adjustment
to change to subscriber liability, if
appropriate (incidental and coding
software denials will remain provider
liability).
For Public Program subscribers, refer to
the Blue Plus Provider Manual.
If the service is
denied, liability may
be changed to
subscriber liability.
See general rules
under “Submission
Guidelines”.
11-13

Coding Policies and Guidelines (Modifiers)
MOD Description Submission Guidelines Impact to Payment
-QJ Services/items
provided to a
prisoner or
patient in state or
local custody,
however the
state or local
government, as
applicable, meets
the requirements
in 42 CFR 411.4
(B)
-QK Medical
direction (by
physician) of
two, three or
four concurrent
procedures by
qualified
personnel
-QS Monitored
anesthesia care
service
-QX CRNA service
with medical
direction by a
physician
-QY Medical
direction of one
Certified
Registered Nurse
Anesthetist
(CRNA) by an
anesthesiologist
11-14
The appropriate use of this modifier is
required for our Government Program and
Public Program subscribers.
The –QJ may be submitted for other
subscribers/products as well, but the
modifier will not affect adjudication.
Append the modifier when the
anesthesiologist supervises more than four
concurrent anesthesia procedures. The
anesthesiologist may perform the induction
and emergence but may not be present
during the entire operative session.
Append the modifier when the
anesthesiologist provides specific
anesthesia services to a particular patient
undergoing a planned procedure including
performing a preanesthetic examination, be
physically present in the operating suite,
monitors the patient’s condition, and is
prepared to furnish anesthesia services as
necessary.
Append the modifier on the CRNA charges
when the anesthesiologist supervises the
CRNA who performed the anesthesia
procedure. The anesthesiologist may
perform the induction and emergence but
may not be present during the entire
operative session.
Append the modifier on the
anesthesiologist charges when the
anesthesiologist supervises the CRNA who
performed the anesthesia procedure. The
anesthesiologist may perform the induction
and emergence but may not be present
during the entire operative session.
Services or items will
deny for Government
Program or Public
Program subscribers.
Payment is made at
the part-time
anesthesia conversion
rate.
Payment is made at
the part-time
anesthesia conversion
rate. Only one –QS
service per day will
be allowed.
Payment is made at
the part-time
anesthesia conversion
rate.
Payment is made at
the part-time
anesthesia conversion
rate.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (10/05/11)

Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (10/05/11)
Coding Policies and Guidelines (Modifiers)
MOD Description Submission Guidelines Impact to Payment
-QZ CRNA service
without medical
direction by a
physician
-TC Technical
component
Append the modifier when the CRNA is
physically present in the operating room,
personally performs the induction and
emergence, and directly monitors the
patient throughout the entire operative
procedure.
Under certain circumstances, a charge may
be made for the technical component
alone. Under those circumstances the
technical component charge is identified
by adding modifier ‘TC’ to the usual
procedure number.
The technical component applies to the
actual physical performance of the service,
which includes the equipment, supplies
and personnel.
Payment is made at
the full-time
anesthesia conversion
rate.
Payment is made
based on the technical
portion of the RVU
associated with the
service.
11-15

Coding Policies and Guidelines (Modifiers)
Anatomical Modifiers The following modifiers indicate a specific anatomic site. Because
these modifiers affect edits and payment we suggest they be
submitted in the first modifier position, if applicable. Appropriate
use of these modifiers may assure correct claims adjudication.
11-16
E1 Upper left eyelid
E2 Lower left eyelid
E3 Upper right eyelid
E4 Lower right eyelid
F1 Left hand second digit
F2 Left hand third digit
F3 Left hand fourth digit
F4 Left hand fifth digit
F5 Right hand thumb
F6 Right hand second digit
F7 Right hand third digit
F8 Right hand fourth digit
F9 Right hand fifth digit
FA Left hand thumb
LC Left circumflex coronary artery
LD Left anterior descending coronary artery
LT Left side (used to identify procedures performed on the left
side of the body)
RC Right coronary artery
RT Right side (used to identify procedures performed on the
right side of the body)
T1 Left foot second digit
T2 Left foot third digit
T3 Left foot fourth digit
T4 Left foot fifth digit
T5 Right foot great toe
T6 Right foot second digit
T7 Right foot third digit
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (10/05/11)

Anatomical Modifiers
(continued)
Modifiers Defined by
DHS
T8 Right foot fourth digit
T9 Right foot fifth digit
TA Left foot great toe
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (10/05/11)
Coding Policies and Guidelines (Modifiers)
The national HCPCS Panel developed several modifiers that could
be defined by the various state Medicaid agencies. The Minnesota
Department of Human Services has defined these as follows.
Each modifier has more than one definition dependent on what
service it is appended to or the program affected. The modifiers are
generally informational only and, with the exception of –U7,
applicable primarily to services for our PMAP and MNCare
subscribers.
U1 Definition 1 = Vulnerable Adult
Case Management
Definition 2 = IEP Physical Therapy
(T1018)
Definition 3 = Access Transportation
Services ATS Coordinator admin fee
(A0080, A0090, A0100, A0110,
A0120, A0140)
Definition 4 = CDCS- Personal
Assistance (T2028)
Definition 5 = Transitional Services-
furniture (T2038)
Definition 6 = Basic complexity
level (Care Coordination/Medical
Home S0280-S0281)
Definition 7 = Added absorbency
(A5421-A4554)
Definition 8 = Dialectical Behavior
Therapy (H2019)
Append the modifier
if directed to in
guidelines that may
be found elsewhere
in this manual.
11-17

Coding Policies and Guidelines (Modifiers)
Modifiers Defined by
DHS (continued)
11-18
U2 Definition 1 = Home Care Case
Management
Definition 2 = IEP Occupational
Therapy (T1018)
Definition 3 = none
Definition 4 = CDCS – Treatment &
Training (T2028)
Definition 5 = Transitional Services-
supplies (T2038)
Definition 6 = Extended complexity
level (Care Coordination/Medical
Home S0280-S0281)
Definition 7 = Maximum absorbency
(A4521-A4554)
U3 Definition 1 = CW-TCM
Definition 2 = IEP Speech Therapy
(T1018)
Definition 3 = NET Broker admin
fee (A0080, A0090, A0100, A0110,
A0120)
Definition 4 = CDCS-
Environmental Modifications and
Provisions (T2028)
Definition 5 = Approved Assessment
Penalty Reconsideration (T1001)
Definition 6 = Complicating factor,
non-English language (Care
Coordination/Medical Home S0280-
S0281)
Definition 7 = Enhanced service or
item (T1013/Sign or any DMPOS,
etc.) replaces -22 for non-CPT
Append the modifier
if directed to in
guidelines that may
be found elsewhere
in this manual.
Append the modifier
if directed to in
guidelines that may
be found elsewhere
in this manual.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (10/05/11)

Modifiers Defined by
DHS (continued)
U4 Definition 1 = Service provided via
non face-to-face contact, e.g.,
telephone
Definition 2 = IEP Mental Health
Services T1018)
Definition 3 = NET Taxi or equal,
door to door (A0100)
Definition 4 = CDCS (Consumer
Directed Community Support) - Selfdirection
Support Activities (T2028)
Definition 5 = Overnight study
(E0445)
Definition 6 = Complicating factor;
major active mental health condition
(Care Coordination/Medical Home
S0280-S0281)
Definition 7 = Special population
(Substance abuse treatment H2036,
H0005, H2035, H0020)
U5 Definition 1 = Partial Day (DT&H)
(T2020)
Definition 2 = IEP Nursing Services
(T1018)
Definition 3 = NET Taxi or equal,
wheelchair, curb to curb (A0100)
Definition 4 = End tidal CO 2
monitor, monthly rental (E1399)
Definition 5 = Service Units
available through the notice of
termination, reduction or denial of
services (T1019)
Definition 6 = Advanced level
specialist (H0038)
Definition 7 = With medical services
(Substance abuse treatment H2036,
H0005, H2035, H0020)
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (10/05/11)
Coding Policies and Guidelines (Modifiers)
Append the modifier
if directed to in
guidelines that may
be found elsewhere
in this manual.
Append the modifier
if directed to in
guidelines that may
be found elsewhere
in this manual.
11-19

Coding Policies and Guidelines (Modifiers)
Modifiers Defined by
DHS (continued)
11-20
U6 Definition 1= Temporary Service
Increase (T1001, T1019)
Definition 2= IEP
PCA/Paraprofessional Services
(T1018)
Definition 3 = NET Taxi or equal,
wheelchair, door to door (A0100)
Definition 4 = End tidal CO2 spot
check, weekly rental (E1399)
Definition 5 = none
Definition 6 = none
Definition 7 = Parents with children
(Substance abuse treatment H2036,
H0005, H2035)
U7 Definition 1 = Physician Extender
(medical services)
Definition 2 = IEP Assistive
Technology Devices (T1018)
Definition 3 = NET Bus/train,
monthly pass (A0110)
Definition 4 = Oximeter spot check,
weekly rental (E0445)
Append the modifier
if directed to in
guidelines that may
be found elsewhere
in this manual.
Append this
modifier to services
by non-credentialed
or non-enrolled
practitioners when
performing incidentto
services under the
direct supervision.
The services would
be reported under
the directing
physician’s provider
number. The
modifier does not
impact payment.
Append the modifier
if directed to in
guidelines that may
be found elsewhere
in this manual.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (10/05/11)

Modifiers Defined by
DHS (continued)
U8 Definition 1 = Home Based Mental
Health Service
Definition 2 = IEP Special
Transportation (T1018)
Definition 3 = NET Level of need
assessment (LON) (T1023)
Definition 4 = CDCS – Flexible
case management (T2028) separately
recognized component of selfdirection
support services
Definition 5 = none
Definition 6 = none
Definition 7 = With MAT
(medication assisted therapy) dosing
(H2036, H0005, H2035)
U9 Definition 1 = Therapeutic Support
Foster Care
Definition 2 = Behavioral
Programming by Aide (S5135)
Definition 3 = NET level of need
assessment (LON) II (T1023)
Definition 4 = Corporate settings
(S5140, S5141, T2030 TG, T2032,
T2016, T2017)
Definition 5 = none
Definition 6 = none
Definition 7 = All other MAT drugs
(H0020)
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (10/05/11)
Coding Policies and Guidelines (Modifiers)
Append the modifier
if directed to in
guidelines that may
be found elsewhere
in this manual.
Append the modifier
if directed in
guidelines that may
be found elsewhere
in this manual.
11-21

Coding Policies and Guidelines (Modifiers)
Modifiers Defined by
DHS (continued)
11-22
UA Definition 1 = Children’s
Therapeutic Services and Supports
Definition 2 = Night Supervision
(S5135)
Definition 3 = NET Broker review
(T1023)
Definition 4 = PCA Supervision
(T1019)
Definition 5 = Item, service, or
procedure furnished in conjunction
with a demonstration project (E1399,
T1028, S9441)
Definition 6 = none
Definition 7 = Methadone Plus
(H0020)
UB Definition 1 = Non-reservation
American Indian Chemical Health
only
Definition 2 = 24-Hour Emergency
Service (S5135, S5136)
Definition 3 = NET Taxi or equal,
wheelchair, assisted station to station
(A0100)
Definition 4 = DT & H Pilot Rate C
(T2021)
Definition 5 = Out of home Respite
(S5150)
Definition 6 = none
Definition 7 = All other MAT drugs
Plus (H0020)
Append the modifier
if directed to in
guidelines that may
be found elsewhere
in this manual.
Append the modifier
if directed to in
guidelines that may
be found elsewhere
in this manual.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (10/05/11)

Modifiers Defined by
DHS (continued)
UC Definition 1 = Specialized
Maintenance Therapy
Definition 2 = Extended Home Care
Services (T1002-03, T1019, S9128-
29, S9131, S5181)
Definition 3 = MNET – Mileage
provided by licensed foster parent
(A0090)
Definition 4= Waiver Case
Management (T1016)
Definition 5 = C&TC Mental Health
Screening (96110)
Definition 6 = none
Definition 7 = Combination cooccurring
mental health with medical
services (Substance abuse treatment
H2036, H0005, H2035, H0020)
UD Definition 1 = Professional service
for fitting and evaluation of
customized DME/PO (K0115-
K0116)
Definition 2 = Transitioning to
community living services (90882,
H2017)
Definition 3 = NET Fuel Adjustment
Rate (A0100)
Definition 4 = Family Support Grant
(T2025)
Definition 5 = ER Triage (99201,
99211)
Definition 6 = DRA reporting
exception 340B purchased drug
(HCPCS subset requiring NDC)
Definition 7 = Low intensity
(Substance abuse treatment H2036)
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (10/05/11)
Coding Policies and Guidelines (Modifiers)
Append the modifier
if directed to in
guidelines that may
be found elsewhere
in this manual.
Append the modifier
if directed to in
guidelines that may
be found elsewhere
in this manual.
11-23

Chapter 11
Coding Policies and Guidelines
(Anesthesia)
Table of Contents
Overview..............................................................................................................................11-2
Full-time Anesthesia Services.............................................................................................. 11-2
Part-time (Medically Directed) Anesthesia Services...........................................................11-3
Qualifying Circumstances.................................................................................................... 11-3
Physical Status .....................................................................................................................11-4
Qualifying Circumstances and Physical Status Submission................................................ 11-4
Electroconvulsive Treatments.............................................................................................. 11-5
Local Anesthesia.................................................................................................................. 11-5
Medical Services and Invasive Procedures.......................................................................... 11-5
Epidural Anesthesia for a Surgical Procedure ..................................................................... 11-5
Epidural Anesthesia for Pain Management..........................................................................11-5
Anesthesia for Nerve Blocks ............................................................................................... 11-5
Daily Management of Epidural Drug Administration ......................................................... 11-5
Epidural Anesthesia for Labor and Delivery ....................................................................... 11-6
Moderate (Conscious) Sedation...........................................................................................11-7
Monitored Anesthesia Care.................................................................................................. 11-7
Patient Controlled Analgesia ...............................................................................................11-7
Standby ................................................................................................................................11-7
Documentation..................................................................................................................... 11-8
Time Designation/ Submission............................................................................................ 11-8
Diagnosis Coding................................................................................................................. 11-8
Multiple Surgery .................................................................................................................. 11-8
Cardioversion Restriction ....................................................................................................11-8
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (02/21/12) 11-1

Coding Policies and Guidelines (Anesthesia)
Overview Blue Cross and Blue Shield of Minnesota accepts the CPT
American Society of Anesthesiologists codes (ASA), 00100-
01999, for anesthesia services billed on the 837P claim format. We
do not accept surgical codes submitted with anesthesia modifiers.
All services for the same operative session should be submitted on
the same claim.
Full-time Anesthesia
Services
11-2
We define full-time anesthesia as follows:
•
•
•
•
•
•
Full-time anesthesia services are provided personally by the
anesthesiologist to an individual patient. The anesthesiologist
is physically present in the specific operating room, personally
performs the induction and emergence, and directly monitors
the patient throughout the entire operative procedure. The
anesthesiologist may leave the specific operating suite to
perform necessary administrative duties. However, the
anesthesiologist does not perform other revenue-generating
procedures when billing full-time anesthesia services. This
definition includes one-on-one supervision of a certified
registered nurse anesthetist (CRNA) present in the same
operating suite.
Use modifier AA for full-time physician services.
Blue Cross also considers anesthesia services provided by
independent CRNA and physician-employed CRNA to be fulltime
if the above criteria are met and medical direction is not
provided by a physician.
Modifier QZ would be used for full-time CRNA services.
The HCPCS level II modifiers (AA and QZ) should be listed
in the first modifier position.
The anesthesia modifiers should only be reported with the CPT
anesthesia codes 00100-01999. Other services (such as nerve
blocks), may be performed by an anesthesiologist or CRNA,
but should not be submitted with an anesthesia modifier.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (02/21/12)

Part-time (Medically
Directed) Anesthesia
Services
Qualifying
Circumstances
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (02/21/12)
Coding Policies and Guidelines (Anesthesia)
Medically directed anesthesia services are provided by the
anesthesiologist when he or she is supervising two or more
CRNAs. The anesthesiologist may perform the induction and
emergence but is not necessarily present during the entire
operative session and may be supervising two or more procedures
at the same time.
• Use modifier -AD or -QK for the medical direction provided
by a physician (part-time services).
• Use modifier -QY for part-time medical direction of one
CRNA by an anesthesiologist.
• Use modifier -QX for medically directed CRNA services (parttime).
• Modifier -QS would be used for part-time monitored
anesthesia care.
The HCPCS level II modifiers (AD, QK, QS, QX and QY)
should be listed in the first modifier position.
In accordance with CPT, the following circumstances are
recognized for submission of risk. These codes are not stand-alone
services. Qualifying circumstance codes billed without an ASA
service on the same claim will be rejected. The corresponding
eligible base units that may be allowed are also listed. Anesthesia
risk factors will be priced independently of the anesthesia line for
easier posting of payments to accounts and greater accuracy of
payments.
Code Base
Units
Description
99100 1 Anesthesia for patient of extreme age; younger
than 1 year and older than 70
(List separately in addition to the code for the
primary anesthesia procedure.)
99116 5 Anesthesia complicated by utilization of total
body hypothermia
(List separately in addition to the code for the
primary anesthesia procedure.)
99135 5 Anesthesia complicated by utilization of
controlled hypotension
(List separately in addition to the code for the
primary anesthesia procedure.)
11-3

Coding Policies and Guidelines (Anesthesia)
11-4
Code Base
Units
Description
99140 2 Anesthesia complicated by emergency
conditions (specify)
(List separately in addition to the code for the
primary anesthesia procedure.) (An emergency is
defined as existing when delay in treatment of
the patient would lead to a significant increase in
the threat of life or body part.)
Physical Status Six levels are currently recognized for patient physical status that
may be used to distinguish various levels of complexity of the
anesthesia service provided. Submit these physical status modifiers
in the second modifier position, on the same line as the anesthesia
service code. The corresponding eligible base units that may be
allowed are also listed.
Qualifying
Circumstances and
Physical Status
Submission
Modifier
Base
Units Description
P1 0 Normal, healthy patient
P2 0 Patient with mild systemic disease
P3 1 Patient with severe systemic disease
P4 2 Patient with severe systemic disease that is a
constant threat to life
P5 3 A moribund patient who is not expected to
survive without the operation
P6 0 Declared brain-dead patient whose organs are
being removed for donor purposes
The example below illustrates a claim that is submitted
appropriately. It is for a situation where both qualifying
circumstances and physical status may apply.
Procedure
Code Modifier Description
00862 AA P3 Anesthesia for extra- peritoneal
procedures in lower abdomen, including
urinary tract; renal procedures, including
upper one-third of ureter, or donor
nephrectomy
Performed by a full-time M.D.
Patient with severe systemic disease
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (02/21/12)

Electroconvulsive
Treatments
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (02/21/12)
Coding Policies and Guidelines (Anesthesia)
99140 Anesthesia complicated by emergency
conditions
To bill for anesthesia for electroshock treatments (00104), submit
the appropriate anesthesia modifier. Time units and risk are
recognized for this service.
Local Anesthesia Local anesthesia, such as a nerve block, is included in the surgical
procedure code. Do not submit a separate charge for this service.
Medical Services and
Invasive Procedures
Epidural Anesthesia for
a Surgical Procedure
Epidural Anesthesia for
Pain Management
Anesthesia for Nerve
Blocks
Daily Management of
Epidural Drug
Administration
Anesthesia HCPCS Level II modifiers should be submitted with
ASA codes only. Do not submit anesthesia modifiers with medical
services such as hospital visits, consultations, ventilation
management, CPR, daily epidural management, or with invasive
procedures such as vascular injections or nerve blocks.
The insertion and administration of an epidural by an anesthesia
provider for anesthesia during a surgical procedure should be
reported with the appropriate anesthesia code. Codes 62311, 62318
or 62319 should not be used.
The insertion of an epidural catheter for pain management services
by a qualified provider should be reported with either code 62311,
62318 or 62319, as appropriate. Time units are not appropriate for
codes 62311, 62318 and 62319, and anesthesia modifiers are not
required.
Anesthesia services for diagnostic or therapeutic nerve blocks and
injections are submitted under codes 01991 or 01992 only when a
different provider performs the block or injection.
Daily management of an epidural catheter performed on the same
date as the insertion of the catheter is considered to be included in
the insertion and should not be reported separately.
Subsequent daily management of epidural drug administration in
the inpatient setting, including daily visits and removal of the
epidural catheter, may be reported using CPT code 01996 (daily
hospital management of epidural or subarachnoid drug
administration).
Do not submit anesthesia modifiers or time for epidural daily
management.
Removal of the epidural catheter alone does not constitute daily
management. If the only service performed is removal of the
catheter, code 01996 should not be reported. Subsequent daily
management of an epidural catheter performed in a setting other
than inpatient hospital should be reported using the appropriate
Evaluation and Management code.
11-5

Coding Policies and Guidelines (Anesthesia)
Epidural Anesthesia for
Labor and Delivery
11-6
Insertion Only
When a provider performs the insertion of an epidural catheter for
continuous analgesia, but does not participate in the ongoing
management and monitoring of the epidural analgesia for labor
and delivery, the claim should be for the insertion service only
(code 62319). Time units are not appropriate for code 62319, and
anesthesia modifiers are not required.
Insertion and Management
When a provider inserts the epidural catheter and participates in
ongoing management and monitoring of the patient's epidural
analgesia, the anesthesia code 01967 and (if applicable) 01968
should be reported for the complete service using the appropriate
anesthesia modifier, with anesthesia time units for actual face-toface
time. It would not be appropriate to report 62319 for the
insertion of the catheter in addition to the epidural management.
99140
It is also not appropriate to bill the emergency qualifying
circumstance code (99140) with normal deliveries. Emergency
code 99140 applies only to cases where a “delay in treatment
would result in an increased risk to life or body part,” according to
the ASA Relative Value Guide. Do not confuse an inconvenient
case with emergencies, such as a surgery that takes place on the
weekend or after normal business hours.
Management Only
In many cases, a physician will insert the epidural catheter, but a
CRNA is responsible for the ongoing management and monitoring
of the patient’s epidural analgesia. When this is the case, the
CRNA should submit the anesthesia code 01967 (if applicable)
and 01968 using the appropriate anesthesia modifier, with
anesthesia time units for actual face-to-face time.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (02/21/12)

Moderate (Conscious)
Sedation
Monitored Anesthesia
Care
Patient Controlled
Analgesia
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (02/21/12)
Coding Policies and Guidelines (Anesthesia)
The physician who performs a procedure may bill moderate
sedation, codes 99143-99145, in addition to billing the procedure.
The use of these codes requires and includes an independent
trained observer. The observer is not eligible to bill for anesthesia.
Do not submit an anesthesia modifier with these codes.
When a second physician, other than the healthcare professional
performing the procedure, provides moderate sedation in the
facility setting (e.g., hospital, outpatient hospital/ambulatory
surgery center) the second physician reports 99148-99150. Codes
99148-99150 may not be reported in a non-facility setting (e.g.,
office).
Do not submit 99143-99150 with procedures that include
conscious sedation as an inherent part of providing the procedure.
These procedures are listed in Appendix G of the 2012 CPT
manual. The target symbol () will precede applicable codes in
the main body of the CPT manual.
Monitored anesthesia care (MAC) refers to instances in which an
anesthesiologist has been called on to provide specific anesthesia
services to a particular patient undergoing a planned procedure. In
this case, the physician performs a preanesthetic examination, is
physically present in the operating suite, monitors the patient’s
condition, makes medical judgments regarding the patient’s
anesthesia needs, and is prepared to furnish anesthesia service as
necessary.
For those circumstances under which such care is medically
necessary and requested by the performing surgeon, Blue Cross
will allow submission for MAC the same as for any other
anesthesia service.
Use modifier -QS for monitored anesthesia services.
Blue Cross recognizes that patient-controlled analgesia (PCA) has
demonstrated clear value to the patient. However, we do not
recognize a separate charge for this service because postoperative
pain control has already been included in the reimbursement of the
surgical fee, which was paid to the performing surgeon. Patient
controlled analgesia is also given to patients who have not had
surgery (such as cancer patients) for pain control. It will be
covered in such cases.
Standby Anesthesia standby occurs when an anesthesiologist or CRNA is
present in case his or her services are required for anesthesia, but
otherwise performs no medical intervention. Blue Cross does not
cover anesthesia standby. Standby services (99360) are considered
ineligible and should not be billed to Blue Cross or the patient.
11-7

Coding Policies and Guidelines (Anesthesia)
Documentation The anesthesia record (either at the facility or the provider’s office)
must clearly identify the professional or professionals providing
the anesthesia service. For legal reasons, and in order to justify
charges, Blue Cross requests that both the CRNA and
anesthesiologist signatures be present for medically directed care.
Time Designation/
Submission
11-8
Anesthesia time should be indicated on the 837P claim format in
the unit(s) field of the 837P record. Anesthesia time begins when
the anesthesiologist or CRNA begins to prepare the patient for the
induction of anesthesia in the operating room, or an equivalent
area, and ends when they are no longer in personal attendance.
Code the anesthesia time as minutes in the units of service field.
Diagnosis Coding Use ICD-9-CM diagnosis codes. Select the diagnosis code that
best describes the reason for the surgery based on the patient’s
medical record. Diagnosis code V50.1, plastic surgery for
unacceptable cosmetic surgery appearance, may be submitted
when the patient has requested elective surgery and that is the only
surgery performed during an operative session.
Multiple Surgery Code anesthesia services associated with multiple or bilateral
surgical procedures performed during the same operative session
with the single anesthesia code that has the highest base unit value.
Cardioversion
Restriction
Cardioversion, CPT code 92960 (cardioversion, elective, electrical
conversion of arrhythmia; external) will not be allowed if
submitted by a certified registered nurse anesthetist.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (02/21/12)

Chapter 11
Coding Policies and Guidelines
(Behavioral Health)
Table of Contents
Behavioral Health for Professional Billers (837P) ................................................................ 11-4
Introduction..........................................................................................................................11-4
Practitioners Who Should be Using this Section .................................................................11-4
Units.....................................................................................................................................11-4
Coding Restrictions..............................................................................................................11-4
CTSS Skills Training and Development – PMAP/MNCARE Only....................................11-5
Adult Rehabilitation Mental Health Services (ARMHS) – PMAP/MNCARE Only .......... 11-7
Coding for ARMHS – PMAP/MNCARE Only................................................................... 11-7
Eligible Groups for ARMHS ...............................................................................................11-8
Assertive Community Treatment (ACT) ............................................................................. 11-8
Billing for ACT....................................................................................................................11-8
Intensive Residential Treatment Services (IRTS) (Medicaid Government Programs Only)11-9
IRTS/Crisis Provider Eligibility ........................................................................................11-10
IRTS Member Eligibility ...................................................................................................11-11
IRTS Access to Services....................................................................................................11-11
Billing for IRTS or Residential Crisis ...............................................................................11-11
Adult Non-Residential Crisis Services - Public Program Members Only......................... 11-12
MH-TCM Services to Minnesota Health Care Programs.................................................. 11-14
Dialectical Behavioral Therapy/DBT - MHCP Members Only ........................................11-16
Autism Spectrum Disorder/EIBI........................................................................................11-18
Psychiatric Consultation to Primary Care Practitioners.....................................................11-22
Psychiatry and Chemical Dependency Assessments .........................................................11-25
MHCP Screening Requirements........................................................................................ 11-25
Family Therapy..................................................................................................................11-26
Units for Public Program Members ................................................................................... 11-26
Medication Management ...................................................................................................11-27
Behavioral Health Evaluation & Management (E&M) Office Calls.................................11-28
Nutritional Counseling/Medical Nutrition Therapy Services............................................11-29
Eligibility of Dietitians/ Nutritionists ................................................................................11-30
Psychological and Neuropsychological Testing ................................................................11-30
Testing Policy ....................................................................................................................11-31
Practitioner Key .................................................................................................................11-37
Policies...............................................................................................................................11-38
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12
11-1

Coding Policies and Guidelines (Behavioral Health)
11-2
Clinical Supervision Under Minnesota Rule Part 9505.0371 - MHCP Members Only.... 11-39
DIAMOND Initiative ........................................................................................................ 11-40
Marital Counseling ............................................................................................................ 11-41
Opioid Maintenance Drug Therapy................................................................................... 11-41
Tobacco Cessation............................................................................................................. 11-42
Rule 29 Setting .................................................................................................................. 11-43
Day Treatment................................................................................................................... 11-43
Compatibility..................................................................................................................... 11-43
Health and Behavior Assessment and Intervention Codes................................................ 11-44
Missed Appointments........................................................................................................ 11-44
Court Ordered Treatment .................................................................................................. 11-45
Guidelines for Court Ordered Evaluations........................................................................ 11-46
Guidelines for Court Ordered Evaluations – Noncovered Services.................................. 11-49
Parity.................................................................................................................................. 11-51
Behavioral Health Quality Improvement Objectives ........................................................ 11-51
Prior Authorization............................................................................................................ 11-53
Referrals ............................................................................................................................ 11-54
Preadmission Notification ................................................................................................. 11-54
Pre-certification and Concurrent Review for Inpatient/Residential Mental Health and
Substance use Disorder Services....................................................................................... 11-55
Groups that Carve Out Behavioral Health Benefits .......................................................... 11-56
Provider Networks............................................................................................................. 11-57
Professional Behavioral Health Coding Information..........................................................11-59
Behavioral Health for Institutional (837I) Billers ...............................................................11-85
Introduction ....................................................................................................................... 11-85
Practitioners Who Should be Using this Section............................................................... 11-85
Coding Guidelines............................................................................................................. 11-85
Behavioral Health Evaluation or Testing .......................................................................... 11-85
Units .................................................................................................................................. 11-85
Individual Behavioral Health Therapy .............................................................................. 11-86
Family and Group Therapy ............................................................................................... 11-86
Substance Abuse Services ................................................................................................. 11-87
Billing a Behavioral Health Assessment ........................................................................... 11-87
Testing ............................................................................................................................... 11-87
Family Therapy ................................................................................................................. 11-87
Nutritional Counseling/ Dietitians..................................................................................... 11-88
Detox and Alcohol/Drug Rehab Services.......................................................................... 11-89
Health and Behavior Assessment and Intervention Codes................................................ 11-89
Non-Residential Treatment Centers .................................................................................. 11-90
FEP Exclusion of Residential Treatment Centers ............................................................. 11-90
Compatibility..................................................................................................................... 11-90
Recreational Therapy......................................................................................................... 11-90
Extended Care and Halfway House Room and Board (Medicaid Government Programs
Only).................................................................................................................................. 11-91
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12

Coding Policies and Guidelines (Behavioral Health)
Partial Psychiatric Billing ..................................................................................................11-93
Rule 5 - Emotionally Handicapped Facilities ....................................................................11-95
Children’s Residential Mental Health (Medicaid Government Programs only) ...............11-95
IRTS (Medicaid Government Programs Only)..................................................................11-96
IRTS/Crisis Provider Eligibility ........................................................................................11-97
IRTS Member Eligibility ...................................................................................................11-98
IRTS Access to Services....................................................................................................11-98
Billing for IRTS or Residential Crisis ...............................................................................11-98
Court Ordered Treatment...................................................................................................11-98
Preadmission Notification.................................................................................................. 11-99
Residential Substance Abuse Admission and Concurrent Review Process Change .........11-99
Pre-certification and Concurrent Review for Inpatient/Residential Mental Health and
Substance Use Disorder services .....................................................................................11-100
Referrals...........................................................................................................................11-102
Parity................................................................................................................................11-102
Groups that Carve Out Behavioral Health Benefits.........................................................11-103
Provider Networks ........................................................................................................... 11-103
Institutional Behavioral Health Coding Information....................................................... 11-104
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12 11-3

Coding Policies and Guidelines (Behavioral Health)
Behavioral Health for Professional Billers (837P)
Introduction This section of the manual is intended for all behavioral health
practitioners who bill on the professional claim format (837P).
This section is not intended for practitioners whose services are
billed on the institutional claim format (837I).
Practitioners Who
Should be Using this
Section
11-4
Psychiatrists, Ph.D. level psychologists, master’s level
psychologists, licensed independent clinical social workers,
certified nurse specialists in psychiatry, licensed marriage and
family therapists, and psychiatric mental health nurse practitioners.
Behavioral health practitioners in Rule 29 Clinics and Behavioral
Health specialty clinics should bill under the supervising
practitioner's individual provider number and with the U7 modifier
attached to the procedure codes submitted on the claim.
Units One or more units should be submitted based on the time
designation within the HCPCS code narrative. If there is no time
designation, the service is considered ‘per session’ and only one
unit should be submitted regardless of actual time spent.
Coding Restrictions Code Restriction
90845 Psychoanalysis is generally excluded in member
contracts. If it were to be covered, it must be provided
by an MD (psychiatrist).
90846 Family psychotherapy without the patient present may
be excluded in some members’ contracts. It is only
compatible with a behavioral health diagnosis.
90882 Environmental intervention for medical management
purposes is not covered because it is included in the
practitioner's basic service. However, for Public
Program members only, code 90882 is allowed for
transitioning to community living. See the sections on
“Adult Rehabilitation Mental Health Services (ARMHS)
– PMAP/MNCARE Only” and “Coding for ARMHS –
PMAP/MNCARE Only.”
90885 Psychiatric evaluation of hospital records - not covered
because it is included in the practitioner's basic service
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12

Coding Restrictions Code Restriction
CTSS Skills Training
and Development –
PMAP/MNCARE Only
Coding Policies and Guidelines (Behavioral Health)
90887 Interpretation or explanation of exam results is not
covered because reimbursement is included in the
compensation for the practitioner’s basic service billed
with the testing code. This service may be allowed for
Public Program members within the DHS Policy
guidelines of four per year. Services beyond the four
per year will be denied as provider liability.
90889 Preparation of report is a contract exclusion and is not
covered.
90899 Unlisted psychiatric service or procedure codes must be
submitted with a specific narrative description detailing
exactly what the charge is for along with documentation
of time. Unlisted codes may be subject to denial if there
is an existing definitive code describing the service.
Children’s Therapeutic Services and Supports (CTSS) providers
should bill HCPCS code H2014, for skills training and
development services provided to Public Program members. These
services are used exclusively for Public Program members under
the age of 21. The appropriate number of units must be billed with
this code. Each unit equals 15 minutes of service. Providers billing
code H2014 must include the following modifier(s):
UA for individual skills
UA, HR for family skills
UA, HQ for group skills
While the majority of CTSS providers specialize in in-home work,
they can also provide services in the office. H2014 is only one of
many services under the CTSS umbrella. CTSS providers can bill
all the codes that any other licensed mental health professional can
bill. The Skills Training service will often be done by a nonlicensed
practitioner but should always be billed under the
supervising professional’s provider number or NPI.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12 11-5

Coding Policies and Guidelines (Behavioral Health)
CTSS Skills Training
and Development –
PMAP/MNCare Only
(continued)
11-6
Code Restriction
H0046 Mental health services, not otherwise
specified. Use for travel time for in-home
services. Bill 1 unit per 1 minute. A specific
narrative description detailing exactly what
the charge is for must be submitted with this
code.
H2011 Crisis intervention service, per 15 minutes
H2012-UA Behavioral health day treatment, per hour.
Use for therapeutic preschool for Public
Program members.
H2014-UA Skills training and development, per 15
minutes. Use for CTSS individual skills
training and development services. This code
is covered for Public Program members
under age 21.
H2014-U9 Use for TSFC (Therapeutic Support of Foster
Care) service package
H2014-UA,HR Use for CTSS, family skills
H2014-UA,HQ Use for CTSS, group skills
H2015 Comprehensive community support services,
per 15 minutes. Submit with UA modifier for
CTSS Crisis Intervention.
H2019-UA Therapeutic behavioral services, per 15
minutes. Use for CTSS Behavioral Aide level
1 I.
H2019-UA, HM Therapeutic behavioral services, per 15
minutes. Use for CTSS Behavioral Aide
level II.
H2019-UA, HE Therapeutic behavioral services, per 15
minutes. Use for mental health practitioner
direction (supervision) of CTSS Behavioral
Aide.
H2020-UA Therapeutic behavioral services, per diem.
Use for CTSS Behavioral Aide level I.
H2020-UA, HM Therapeutic behavioral services, per diem.
Use for CTSS Behavioral Aide level II.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12

CTSS Skills Training
and Development –
PMAP/MNCare Only
(continued)
Adult Rehabilitation
Mental Health Services
(ARMHS) –
PMAP/MNCARE Only
Coding for ARMHS –
PMAP/MNCARE Only
Code Restriction
Coding Policies and Guidelines (Behavioral Health)
H2020-UA, HE Therapeutic behavioral services, per diem.
Use for mental health practitioner direction
(supervision) of CTSS Behavioral Aide.
H2032 Activity therapy, per 15 minutes. Use for
Therapeutic Camp.
ARMHS is a health plan responsibility for Blue Plus ® Public
Program groups. These services are for members with a serious
mental illness.
The following provider specialties are eligible to provide these
services: Multi-specialty clinics, community mental health
clinics, behavioral health clinics, psychiatrists, Ph.D. level
licensed psychologists, master’s level licensed psychologists,
clinical nurse specialists, licensed independent clinical social
workers, licensed marriage/family therapists, and psychiatric
mental health nurse practitioners.
Eligible providers must be certified through DHS as Adult
Rehab Mental Health Services providers.
Code Restriction
H2017 Psychosocial Rehab (basic social and living
skills) individual by a professional
H2017 – HM Psychosocial Rehab individual by a rehab
worker
H2017 – HQ Psychosocial Rehab group by either a
professional or rehab worker
H2017 – UD Psychosocial Rehab when transitioning to
Community Living Services
90882 Community Intervention by a professional
90882 – HM Community Intervention by a rehab worker
90882 – UD Community Intervention when transitioning to
Community Living Services
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12 11-7

Coding Policies and Guidelines (Behavioral Health)
Eligible Groups for
ARMHS
Assertive Community
Treatment (ACT)
11-8
Code Restriction
H0034 Medication Education individual by a physician,
RN, pharmacist, or PA
H0034 – HQ Medication Education group by a physician, RN,
pharmacist, or PA
Members in the following groups are eligible to receive these
services through Blue Plus:
Products Group Numbers
PMAP PP011, PP012, PP014, PP015, PP016, PP017,
PP021, PP022, PP024, PP025, PP026, PP027,
PP031, PP032, PP034, PP035, PP036, PP037
GA/GAMC PP081, PP082, PP084, PP091, PP092, PP094
Minnesota
Senior Care
Plus
MinnesotaCare
Expanded
MinnesotaCare
Basic Plus,
Basic +1,
Basic +2
SecureBlue SM
(HMO SNP)
PP041, PP042, PP044, PP051, PP052, PP054,
PP055, PP056, PP057, PP061, PP062, PP064,
PP071, PP072, PP074, PP075, PP076, PP077
PP111, PP112, PP151, PP152
PP121, PP122, PP131, PP132, PP141, PP142,
PP161, PP162, PP163, PP164
PP200, PP201, PP202, PP210, PP215, PP220,
PP221, PP222, PP230, PP240, PP245, PP250,
PP255, PP260, PP261, PP262, PP270, PP280,
PP281, PP282, PP290
To provide this type of treatment, providers must:
Be certified by DHS to provide ARMHS
Be a participating provider with Blue Cross and Blue Shield of
Minnesota (Blue Cross)
Billing for ACT Services must be billed on an 837P electronic claim format
Use HCPCS code H0040 (ACT Program per diem)
For each line item billed, an individual mental health
professional or mental health rehab professional provider
number must be submitted in loop 2310B of the electronic
claim.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12

Intensive Residential
Treatment Services
(IRTS) (Medicaid
Government Programs
Only)
Coding Policies and Guidelines (Behavioral Health)
Blue Cross will reimburse certain categories of providers for these
services, which were formerly reimbursed through the Minnesota
Department of Human Services (DHS).
This change was effective for all enrollees in the Prepaid Medical
Assistance Programs (PMAP), Minnesota Senior Health Options
(MSHO) and Minnesota Disabled Health Options (MnDHO).
Crisis response services include:
Crisis assessment
Crisis intervention
Crisis stabilization
Community intervention
The following summarizes provider eligibility, member eligibility
and operational requirements for Blue Plus providers of these
services.
All members of the following Blue Plus products are eligible to
receive these services:
Blue Advantage (Blue Plus PMAP, and Minnesota Senior
CarePlus)
MinnesotaCare
CareBlue
Group numbers for these products are listed below.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12 11-9

Coding Policies and Guidelines (Behavioral Health)
Intensive Residential
Treatment Services
(IRTS) (Medicaid
Government Programs
Only) (continued)
IRTS/Crisis Provider
Eligibility
11-10
Blue Plus
Products Group Numbers
Blue Advantage PP011, PP012, PP014, PP015, PP016,
PP017, PP021, PP022, PP024, PP025,
PP026, PP027, PP031, PP032, PP034,
PP035, PP036, PP037, PP411, PP412,
PP414
Minnesota Senior
Care Plus
MinnesotaCare
Expanded
MinnesotaCare
Basic Plus, Basic
+1, Basic +2
PP041, PP042, PP044, PP051, PP052,
PP054, PP055, PP056, PP057, PP061,
PP062, PP064, PP071, PP072, PP074,
PP075, PP076, PP077
PP111, PP112, PP151, PP152
PP121, PP122, PP131, PP132, PP141,
PP142, PP161, PP162, PP163, PP164
SecureBlue PP200, PP201, PP202, PP215, PP220,
PP221, PP222, PP240, PP245, PP260,
PP261, PP262, PP280, PP281, PP282
Members with commercial coverage may be eligible to receive
these services. Please verify member eligibility using one of the
resources described below under Member eligibility.
To provide this type of treatment, providers must:
Be licensed under Rule 36
Have DHS approval
Be a participating provider with Blue Cross
Professional treatment services may only be provided by an
eligible IRTS Crisis provider.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12

IRTS Member
Eligibility
IRTS Access to
Services
Billing for IRTS or
Residential Crisis
Coding Policies and Guidelines (Behavioral Health)
Providers are expected to check the member’s eligibility before
rendering services. Resources available for verification include:
MN-ITS
www.mn-its.dhs.state.mn.us
EVS
1-800-657-3613
Provider Web Self-Service
www.providerhub.com
Provider Services
1-800-262-0820
Direct access to contracted providers
No prior authorizations required
No referrals required
Non-contracted providers must obtain a referral from provider
services at 1-800-262-0820 prior to delivering treatment.
When reporting room and board and/or treatment services, report
on the 837I type of bill 86X, with the room and board and
treatment services as separate line items. Submit the room and
board charges under revenue code 1001 and the treatment services
under revenue codes 090X or 091X.
When room and board and treatment are billed to separate entities,
treatment is reported on the 837P, with HCPCS code H0018 or
H0019.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12 11-11

Coding Policies and Guidelines (Behavioral Health)
Adult Non-Residential
Crisis Services - Public
Program Members
Only
11-12
Per the Department of Human Services (DHS), adult nonresidential
crisis services for behavioral health diagnoses are a
covered service for some Minnesota Health Care Program (Public
Programs) members.
Eligible providers must be enrolled through DHS.
Eligible providers must be enrolled through DHS as Adult
Crisis Response Providers.
Blue Cross has adopted the same coding changes as outlined below
by the Minnesota Department of Human Services. This change is
effective for all Minnesota Health Care Programs (MHCP)
members.
Adult Mental Health Crisis Services
Use HCPCS code S9484 to bill for adult mental health crisis
services, combining crisis assessment, intervention and nonresidential
stabilization. This coding:
complies with HIPAA coding requirements
creates consistency between adult and children’s crisis service
billing
eliminates arbitrary distinction between intervention and
assessment
Do not use HCPCS code H0031 for crisis assessment or H2011 for
crisis intervention.
The following services may be submitted on an 837P claim format.
Enter the actual place of service code (POS); POS may not be 23
(emergency department) for mobile team billing.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12

Adult Non-Residential
Crisis Services - Public
Program Members
Only (continued)
Adult Crisis Service Billing
Coding Policies and Guidelines (Behavioral Health)
Code Description Of Service Billing Unit
S9484 adult crisis assessment,
intervention and stabilizationindividual,
professional
S9484-HM adult crisis stabilization –
individual rehab worker
S9484-HN adult crisis assessment,
intervention and stabilization
– individual practitioner
1 unit per 60
minutes
1 unit per 60
minutes
1 unit per 60
minutes
S9484-HQ adult crisis stabilization-group 1 unit per 60
minutes
Additional information
Rehabilitation workers can provide adult crisis stabilization
services only.
The changes listed above do not apply to the coverage, coding or
authorization thresholds for residential crisis stabilization (H0018)
or community intervention (90882).
Pricing and Programs Applicability
Blue Cross’ usual pricing methodology for Public Programs will
apply to these codes. This information applies to the following
programs:
Prepaid Medical Assistance Program (BlueAdvantage/
PMAP/GAMC) – all groups
Minnesota Senior Health Options (MSHO SecureBlue)
Minnesota Senior Care Plus (BlueAdvantage MSC+) – all
groups
Minnesota Care – all groups
Group Numbers
A complete listing of group numbers can be found on the Blue
Cross website at bluecrossmn.com.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12 11-13

Coding Policies and Guidelines (Behavioral Health)
MH-TCM Services to
Minnesota Health Care
Programs
11-14
The Minnesota Department of Human Services (DHS) has
determined that managed care organizations that contract with
DHS shall be responsible for the provision of mental health –
targeted case management (MH-TCM) services for eligible
Minnesota Health Care Programs members.
Eligibility
As a contracted provider, your agency must meet Rule 79 criteria
and be designated by Blue Plus in order to be eligible for
reimbursement for MH-TCM services. Providers are responsible
for checking the member’s eligibility prior to rendering services.
Resources available for verification include:
MN-ITS – www.mn-its.dhs.state.mn.us
Provider web self-service – providerhub.com
Nonparticipating providers must obtain a referral prior to rendering
services for Blue Plus members. Contact provider services at
(651) 662-5200 or 1-800-262-0820 for assistance.
Billing
MH-TCM is a professional service billed on an 837P claim format.
When billing for MH-TCM, submit the contracting provider NPI
number currently on file with Blue Plus. In addition, an individual
rendering NPI number is required.
Eligible Minnesota Health Care Programs
Product Name Group Numbers
Prepaid Medical Assistance
Program (PMAP) and
Minnesota Senior Care Plus
(MSC+)
All group numbers that begin
with PP0 and FPG04
MinnesotaCare All group numbers that begin
with PP1 and FPG10
MSHO – SecureBlue All group numbers that begin
with PP2
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12

MH-TCM Services to
Minnesota Health Care
Programs (continued)
Access to Services
Coding Policies and Guidelines (Behavioral Health)
Members have direct access to contracted MH-TCM providers.
Blue Plus members:
No prior authorizations required
Members must be determined eligible for MH-TCM
according to Rule 79 criteria
Providers must be contracted and designated by Blue Plus
Nonparticipating providers must obtain a referral prior to rendering
services for Blue Plus members. Contact provider services at
(651) 662-5200 or 1-800-262-0820 for assistance.
Billing
MH-TCM is a professional service billed on an 837P claim format.
When billing for MH-TCM, submit the contracting provider NPI
number currently on file with Blue Plus. In addition, an individual
rendering NPI number is required.
Procedure
Codes
Modifiers Brief Description Service
Limitations
T2023 HE, HA Face-to-face
contact between
case manager and
recipient under age
18 years
T2023 HE Face-to-face
contact between
case manager and
recipient age 18 or
older
T2023 HE, U4 Telephone contact
(recipient 18 years
or older)
1 unit per
month
1 unit per
month
1 unit per
month
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12 11-15

Coding Policies and Guidelines (Behavioral Health)
MH-TCM Services to
Minnesota Health Care
Programs (continued)
Dialectical Behavioral
Therapy/DBT - MHCP
Members Only
11-16
Procedure
Codes
T1017 for
HIS/638 and
FQHC billing
only
T1017 for
HIS/638 and
FQHC billing
only
Reimbursement
Modifiers Brief Description Service
Limitations
HE, HA Face-to face
encounter (child
under age 18
years)
HE Face-to face
encounter (age 18
or older)
Per encounter
Per encounter
For MH-TCM, eligible providers should bill 100% of the thencurrent
monthly rate established with the county. Blue Plus
reimbursement will be 100% of charge. Providers shall accept this
reimbursement as payment in full for MH-TCM services.
MHCP adds Dialectical Behavior Therapy (DBT) to covered
mental health outpatient benefits for some MHCP members. The
Minnesota Department of Human Services (DHS) received federal
approval on October 1, 2010, to add DBT face-to-face services as
an outpatient mental health benefit. This benefit addition is
effective immediately.
Subscriber must meet all of the following eligibility
requirements:
Subscriber must be age eighteen (18) or older
Subscriber must be diagnosed with severe symptoms and
significant dysfunction consistent with the current Diagnostic
and Statistical Manual of Mental Disorders (DSM) criteria for
a Borderline Personality Disorder
Subscriber’s mental health needs cannot be met with available
community-based services or must be provided concurrently
with other community-based services
Subscriber understands and is cognitively capable of
participating in programming
Subscriber is willing and able to follow program policies and
rules assuring safety of self and others
Subscriber is at significant risk of one or more of the
following; a mental health crisis, entering a more restrictive
setting, decompensating functioning or mental health
symptoms, engaging in intentional self-harm
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12

Dialectical Behavioral
Therapy/DBT - MHCP
Members Only
(continued)
Coding Policies and Guidelines (Behavioral Health)
This information applies to the following programs and all
subgroups for the group numbers listed:
BlueAdvantage
PMAP (age 18
and older)
MinnesotaCare
(age 18 and
older)
BlueAdvantage
MSC+
SecureBlue
(HMO SNP)
Provider eligibility requirements:
PP011, PP012, PP014, PP015, PP016, PP017,
PP021, PP022, PP024, PP025, PP026, PP027,
PP031, PP032, PP034, PP035, PP036, PP037,
PP411, PP412, PP414
PP111, PP112, PP121, PP122, PP131, PP132,
PP141, PP142, PP151, PP152, PP161, PP162,
PP163, PP164
PP041, PP042, PP044, PP051, PP052, PP054,
PP055, PP056, PP057, PP061, PP062, PP064,
PP071, PP072, PP074, PP075, PP076, PP077
PP200, PP201, PP202, PP215, PP220, PP221,
PP222, PP240, PP245, PP260, PP261, PP262,
PP280, PP281, PP282
Provider shall be certified by DHS to provide DBT services
Provider shall meet all Blue Cross credentialing requirements
Provider shall be a participating provider with Blue Cross
Claims submission requirements:
Submit claims on the electronic 837P (professional) format
Both a type 1 NPI (rendering provider) and type 2 NPI (billing
provider) are required on the claim
Submit individual services using HCPCS code H2019 with the
U1 modifier (services must be face-to-face)
Submit group services using HCPCS code H2019 with the U1
and the HQ modifiers (services must be face-to-face)
Payment information
Payment for eligible health services provided to MHCP
subscribers shall be subject to the terms and provisions described
in the Provider Service Agreement as renewed annually.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12 11-17

Coding Policies and Guidelines (Behavioral Health)
Autism Spectrum
Disorder/EIBI
11-18
Early Intensive Behavioral Intervention (EIBI) is a term used to
describe an intensive, multidisciplinary approach used to treat the
symptoms of a diagnosis of autism spectrum disorder (ASD). This
area lacks standard terminology, but does include intensive early
intervention behavioral therapy (IEIBT), applied behavioral
analysis (ABA), Lovaas and discrete trial training (DTT).
To ensure members receive the appropriate quality and level of
care for autism spectrum disorders (ASD) and autism early
intensive behavioral interventions (EIBI), providers should refer to
Blue Cross medical policy (X-44, Autism spectrum disorder:
Early intensive behavioral interventions (EIBI)) relating to
assessment of autism spectrum disorder that includes steps to
follow when providing early intensive behavioral interventions.
Autism spectrum disorder: Assessment
Autism spectrum disorder: Early intensive behavioral
interventions (EIBI)
A summary of the medical policies are available on
providers.bluecrossmn.com.
Product application
EIBI services are subject to the member’s plan benefits. Some
benefit plans may exclude coverage of EIBI services.
Pre-certification/pre-authorization review applies to all EIBI
services for members in fully insured and self-insured benefit
plans, Blue Advantage (PMAP) programs, and MinnesotaCare
programs when the provider of the service is a participating
provider caring for Blue Cross Minnesota members. This does not
include members of other Blue Cross plans.
Pre-certification/pre-authorization review for EIBI services is not
required for members in the following plans:
Minnesota Senior Care Plus (MSC+)
SecureBlue (HMO SNP)
Platinum Blue (Cost)
MedicareBlue PPO (Regional PPO)
Medicare supplement
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12

Autism Spectrum
Disorder/EIBI
(continued)
ASD Assessment Requirements
Coding Policies and Guidelines (Behavioral Health)
To ensure appropriate care and use of benefits, Blue Cross requires
the following to be done prior to the initiation of health services
for EIBI:
A comprehensive diagnostic assessment must have been
completed within the past 12 months.
The assessment must be on file in the provider’s office as part of
each patient’s medical record.
In addition, providers are expected to follow the diagnostic
assessment standards as described in the assessment section of the
Blue Cross behavioral health medical policy, autism spectrum
disorder.
Pre-certification/pre-authorization requirements
Pre-certification/pre-authorization will be required for all EIBI
services (procedure codes H2014, H2017 and H2019) in
which the level of treatment provided consists of more than
nine (9) hours per week for intensive therapy. A week is
defined as a period of seven consecutive days.
A summary of the components of the multidisciplinary
Diagnostic Assessment as described in the Autism Spectrum
Disorders: Assessment Medical Policy X-43, must be included
with the authorization request.
A one-visit Diagnostic Assessment (procedure codes 90801 or
90802) may be completed without pre-certification.
Any psychological or neuropsychological testing also requires
pre-certification/pre-authorization before performing services
for a member.
Pre-certification/pre-authorization requirement applies to all
participating providers.
Obtaining pre-certification/pre-authorization
Providers can obtain pre-certification/pre-authorization for EIBI
assessment/services by completing the Early Intensive Behavioral
Intervention Autism Spectrum Disorder Service request form,
which can be found at providers.bluecrossmn.com. Click on
“Forms & publications.” From the drop-down box choose “forms:
preadmission/prior authorization.” The completed form may be
faxed to (651) 662-0854.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12 11-19

Coding Policies and Guidelines (Behavioral Health)
Autism Spectrum
Disorder/EIBI
(continued)
11-20
Claims audits
Routine claim audits have disclosed occurrences where some
providers have been submitting claims for EIBI services that do
not meet medical policy criteria. This is a reminder that providers
must abide by the requirements of all medical policies.
This action is being taken to help ensure that members receive the
appropriate level of care and frequency of service for EIBI
services. Failure to provide evidence of medical necessity may
result in claim denials.
Coding
Self-insured and fully insured plans except for MHCP:
Provider shall submit claims for EIBI services for autism
spectrum disorder using HCPCS codes H2014, H2017 or
H2019. Provider shall only bill for 15 minute face-to-face
sessions, which shall have a value of one (1) unit. The codes
listed above replace the use of CPT code 90899.
MHCP
For MHCP subscribers eligible for children’s therapeutic
services and supports (CTSS) provider shall submit claims for
EIBI services for autism spectrum disorder using HCPCS
codes H2014-UA, H2017 or H2019-UA. Code H2017 is not a
CTSS code; therefore, it should not be billed using the UA
modifier. Provider shall only bill for 15 minute face to-face
sessions, which shall have a value of one (1) unit. The codes
listed above replace the use of CPT code 90899.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12

Autism Spectrum
Disorder/EIBI
(continued)
Coding Policies and Guidelines (Behavioral Health)
HCPCS codes H2018 and H2020:
Blue Cross will accept HCPCS codes H2018 and H2020 but
will not allow reimbursement for these codes. Provider shall
submit the timed codes listed above for reimbursement for
EIBI services.
Other Blue Cross Plans
If a provider is working with Blue Plans outside of Minnesota, it
may be helpful to identify the code that will be used on the claim
when checking subscriber eligibility and benefit information. This
may help to ensure accurate eligibility and benefit information
prior to the delivery of EIBI services.
Reimbursement
In accordance with a commitment to health care affordability and
administrative simplification, payment for EIBI services for all
eligible Blue Cross subscribers shall remain subject to the terms
and provisions described under Provider Reimbursement,
Minnesota Health Care Programs in the Agreement as renewed
annually by Blue Cross less subscriber and other party liabilities
(e.g., deductibles, coinsurance, non-covered services and
coordination of benefits with other health plans, employer liability
plans, workers’ compensation or automobile plans). Provider
agrees to not request reimbursement for simultaneously provided
individual and family services.
Medical Policies and Procedures Related to ASD
Providers must comply with all medical policy and procedures
including the medical policy and procedures for services rendered
for autism spectrum disorder.
Client Related Activity
Any client related activity that is not face-to-face service shall not
be billed separately. Reimbursement for subscriber related activity
that is not a face-to-face service is included in the rate paid for the
codes stated above.
Adherence and Enforcement of Policy
Blue Cross retains the right to audit provider’s compliance with the
aforementioned coding and reimbursement provisions to ensure
proper administration of subscriber benefits and payment for
services.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12 11-21

Coding Policies and Guidelines (Behavioral Health)
Psychiatric
Consultation to
Primary Care
Practitioners
11-22
The Department of Human Services (DHS) has federal approval to
add psychiatric consultation to mental health covered services.
This includes psychiatric consultation by a psychiatrist via
telephone, e-mail, facsimile, or other means of communication to
primary care practitioners.
Eligibility is extended to all Blue Cross fully insured members and
self-insured members whose groups have elected this coverage.
Psych Consult to PCP Policy
Psychiatric consultation by a psychiatrist via telephone, e-mail,
facsimile, or other means of communication to a primary care
practitioners is subject to the following coverage criteria.
Premises Underlying Psychiatric Consultation
Psychiatric consultations must be:
documented in the patient record and maintained by the
primary care practitioner
between the physician and psychiatrist, compliant with HIPAA
privacy and security requirements and regulations
provided according to federal requirements and data privacy
provisions
With the patient’s consent, psychiatric consultation may be
without the patient present.
Eligible Recipients
To be eligible for psychiatric consultations to primary care
practitioners, recipients:
must be eligible for Blue Plus Public Programs through
Medical Assistance (MA), General Assistance Medical Care
(GAMC) or MinnesotaCare OR must be a fully insured
member, or a self-insured member whose group has elected
this coverage, and
must be under the care of a primary care physician, and require
the consultation between a psychiatrist and their primary care
practitioner for appropriate medical or mental health treatment,
and
may be any age
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12

Psychiatric
Consultation to
Primary Care
Practitioners
(continued)
Eligible Providers
Coding Policies and Guidelines (Behavioral Health)
Providers eligible to request a psychiatric consultation:
Primary care physicians
Nurse practitioners
Clinical nurse specialists
Physician assistants
Only psychiatrists are eligible to provide psychiatric consultation
to primary care practitioners.
Provider Responsibilities
Only the primary care provider may bill for psychiatric
consultations to primary care practitioners.
Primary care clinics and the consulting psychiatrists should
have a contract or other formal agreement that defines the
strategy for payment to the consulting psychiatrist and ensures
that provider requirements and responsibilities are met.
Providers must obtain and maintain HIPAA-compliant
technology and use HIPAA-compliant privacy and security
protections for the recipient. Also, providers must ensure
procedures are in place to prevent a breach in privacy or cause
exposure of recipient mental health records to unauthorized
persons.
Covered Service
Communication between a primary care provider and a psychiatrist
for consultation or medical management of patients is a covered
service.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12 11-23

Coding Policies and Guidelines (Behavioral Health)
Psychiatric
Consultation to
Primary Care
Practitioners
(continued)
11-24
Billing
Use the following code and modifiers to report this service:
99499 – Unlisted evaluation and management service. A
narrative must be submitted as well as the time spent for this
service. This should be reported in the NTE segment of the
837P electronic claim format as “(amount of time) spent in
telephone consultation with (name of psychiatrist).”
Appropriate modifiers as follows:
Basic Consultation: U4, HE
Intermediate Consultation: U4, U5, HE
Complex Consultation: U4, U6, HE
U4 – Case Management via Telephone
The U4 identifies the service as a telephone call.
HE – Mental Health Program
The HE modifier identifies the service as mental health.
Also add modifier -U7 to the appropriate code when the
primary care is provided by a physician extender.
The recipient must be present unless the recipient has granted
permission for the consultation to take place without the recipient
being present.
Authorization requirements, maximum utilization limits and
thresholds do not currently apply to psychiatric consultation codes.
Note: Telephone service codes 99441-99443 and 98966-98968 are
not allowed and will deny as provider liability if submitted.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12

Psychiatry and
Chemical Dependency
Assessments
MHCP Screening
Requirements
90801 and 90802
Coding Policies and Guidelines (Behavioral Health)
These are “per session” codes. Bill one unit of service per
session regardless of time.
These codes can be billed with either a chemical dependency
diagnosis or with a psychiatric condition diagnosis.
If the assessment does not reveal a behavioral health condition,
it would be appropriate to bill with the sign or symptom
precipitating the assessment.
Rule 25 – chemical dependency assessors should submit their
assessments with a 90801 or 90802 code on an 837P claim
format.
The 2011 Minnesota State Legislature passed Minnesota Session
Laws 2011, First Special Session, Chapter 9, Article 8, Section 9.
The legislation directs the Department of Human Services
commissioner to require individuals performing chemical
dependency or mental health diagnostic assessments to use the
approved standardized screening tools to identify whether the
individual being assessed screens positive for a co-occurring
mental health or chemical dependency disorder.
Blue Cross directs participating providers who provide mental
health diagnostic assessments and chemical dependency
assessments for MHCP members to comply with this Legislation.
Follow the instructions related to the screening process and
screening tools provided by the Minnesota Department of Human
Services (DHS) in Bulletin 12-53-01 published on January 5,
2012.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12 11-25

Coding Policies and Guidelines (Behavioral Health)
Family Therapy 90846
Units for Public
Program Members
11-26
This code is billed for family therapy when the patient is not
present. There may be specific contract exclusions for some
self-insured groups.
This code should be billed under the specific patient, not under
the member.
Bill one unit per session regardless of total time.
This code must be billed with a behavioral health diagnosis.
90847
This code is billed for family therapy when the patient is
present. There may be specific contract exclusions for some
self-insured groups.
This code should be billed under the specific patient, not under
the member.
Bill one unit per session regardless of total time.
This code must be billed with a behavioral health diagnosis.
Psychiatric diagnostic interview exams, family psychotherapy
without the patient present, and family psychotherapy with the
patient present are all allowed for PMAP and MNCare
enrollees, when provided by an MD, LP-PhD., LP-MA,
LICSW, CNS-Psych, PMHNP, LPCC or LMFT.
Note: LPCs and LPCCs are ineligible providers for Minnesota
Health Care Program enrollees.
Codes 90801, 90802, 90846, 90847, 90849, 90853, 90857 and
90887 must only be reported by session, regardless of time.
The unit reported must be “1.” Unit submission for all codes
will be based on the code narrative.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12

Medication
Management
M0064 and 90862
Coding Policies and Guidelines (Behavioral Health)
It is not appropriate to bill a medication management code on the
same day as an evaluation and management code. If both are billed
on the same day, the medication management code will deny as
incidental to the evaluation and management code.
Medication management can be billed by a nurse practitioner,
physician assistant, MD, clinical nurse specialist in psychiatry, and
psychiatric mental health nurse practitioner.
Medication management is compatible with a behavioral health
diagnosis.
This service is eligible when billed in the office or skilled nursing
facility. It is not an eligible service when billed with an inpatient
place of service. A medication management visit billed on the
same day as an inpatient visit will deny as incidental to the
inpatient visit.
Medication management rendered in the outpatient clinic setting
should only be billed on an 837P professional claim form. If billed
on a facility claim, it will be denied.
M0064 includes a component for a brief office visit.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12 11-27

Coding Policies and Guidelines (Behavioral Health)
Behavioral Health
Evaluation &
Management (E&M)
Office Calls
11-28
99201-99215
Only an MD is eligible to bill procedure codes 99201-99205 which
are codes for new patients. Procedure codes 99211-99215 (for
established patients) can be billed by an MD, nurse practitioner,
clinical nurse specialist, clinical nurse specialist in psychiatry,
psychiatric mental health nurse practitioner or a physician
assistant.
These E/M services will not be accumulated towards any dollar or
visit maximums.
For complete information on requirements for Minnesota Health
Care Programs, see Chapter 3 of the Blue Plus Manual. Blue Plus
members who receive an E/M service billed with a behavioral
health diagnosis by a non-behavioral health practitioner within
their designated primary care clinic will have services reimbursed
according to their behavioral health contract benefit. Blue Plus
members who receive a behavioral health E/M service by a nonbehavioral
health practitioner outside their primary care clinic but
not within the Select Behavioral Health Network will need an
approved referral to receive their highest level of benefits.
Fee for service (FFS) members who have open access to the
Aware network and who receive a behavioral health E/M service
by a non-behavioral health practitioner will have services
reimbursed according to their behavioral health contract benefit.
Behavioral health E/M services provided outside the Aware
network will be subject to the member’s nonparticipating provider
benefit limitations.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12

Nutritional
Counseling/Medical
Nutrition Therapy
Services
97802-97804, S9470
Coding Policies and Guidelines (Behavioral Health)
Medical nutrition therapy services are usually eligible if billed
with either a behavioral health diagnosis or with a disease related
diagnosis such as obesity or diabetes. Group nutritional therapy
services billed under code 97804 are generally only covered when
submitted with diagnosis codes for anorexia, bulimia, diabetes,
congestive heart failure, and some maternity diagnoses. Obesity is
not an eligible diagnosis for code 97804.
There are no limits to the number of eligible services a patient
receives if the patient has a fully insured contract. In contrast,
some self-insured contracts may choose to apply contract
variations/exclusions for nutritional counseling/medical nutrition
therapy services.
The contract for Federal Employee Program members (who have
ID numbers beginning with “R”) only allows medical nutrition
therapy services in the following situations: Dietitian assessments
as part of a multi-disciplinary eating disorder evaluation; and
medical nutrition therapy services as part of ongoing nutritional
therapy for eating disorders anorexia nervosa (diagnosis code
307.1) and/or bulimia nervosa (diagnosis code 307.51.) Coverage
is extended to diabetic educators, dietitians, and nutritionists who
bill independently as part of a covered diabetic education program
only. Nutritional counseling for up to four visits per year is
covered when billed by a covered provider, although nutritional
counseling for the treatment of anorexia and/or bulimia billed with
diagnosis codes 307.1 or 307.51 is not subject to the four visit
limitation.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12 11-29

Coding Policies and Guidelines (Behavioral Health)
Eligibility of Dietitians/
Nutritionists
Psychological and
Neuropsychological
Testing
11-30
Registered dietitians and licensed nutritionists can bill
independently for procedure codes S9470, 97802, 97803 and
97804 when billed with eating disorder diagnosis codes 307.1,
307.50 and 307.51. No referral is required for the highest benefit
level.
For all other diagnoses, licensed dietitian and nutritionist services
must be submitted to Blue Cross by an eligible medical clinic or
hospital. The individual provider number or NPI of the licensed
dietitian or nutritionist must be submitted on the claim. Licensed
dietitians and nutritionists can bill for procedure codes S9470,
97802 and 97803 for any diagnosis. Procedure code 97804 is not
an eligible service for obesity.
Claims for registered dietitians billing services outside of
behavioral health diagnoses will deny unless the services are
submitted under the individual provider number or NPI of a
supervising physician. The U7 modifier should also be submitted.
96101-96103, 96116, 96118-96125
Each test should be associated with medical necessity and not
be a battery of tests for screening purposes.
Code 90887 (interpretation or explanation of exam results)
should not be billed because reimbursement for these services
is included in the reimbursement for the testing.
The psychological and neuropsychological testing codes reflect
who does the testing: a psychologist, a technician or a
computer. Blue Cross coverage and billing policies for these
codes follows the testing policy below.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12

Coding Policies and Guidelines (Behavioral Health)
Testing Policy The Blue Cross testing policy is found in medical policy X-45,
psychological and neuropsychological testing policy. Medical and
behavioral health policies are available at
providers.bluecrossmn.com under “Medical policy.”
Pre-certification/pre-authorization requirements
Pre-certification/pre-authorization will be required for all
psychological (procedure codes 96101, 96102 and 96103) and
neuropsychological (procedure codes 96116, 96118, 96119,
96120 and 96125) testing before performing services for a
member.
A one-visit Diagnostic Assessment (procedure codes 90801 or
90802) may be completed without pre-certification.
All services are subject to the benefit and network requirement
provisions as written in the member’s plan.
Pre-certification/pre-authorization requirement applies to
Minnesota providers and providers outside of Minnesota.
Obtaining pre-certification/pre-authorization
Providers can obtain pre-certification/pre-authorization for
psychological and neuropsychological testing by completing the
Pre-certification/pre-authorization for psychological and
neuropsychological testing form, which will be available at
providers.bluecrossmn.com. Click on “Forms & publications.”
From the drop-down box choose “forms: pre-admission/prior
authorization.” The completed form may be faxed to
(651) 662-0854.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12 11-31

Coding Policies and Guidelines (Behavioral Health)
Testing Policy
(continued)
11-32
This action is being taken to help ensure that members receive the
appropriate level of care and frequency of service for
psychological and neuropsychological testing. Failure to provide
evidence of medical necessity may result in claim denials with the
outcome of provider liability.
The pre-certification/pre-authorization protocol parallels the
process utilized for other medical/surgical services.
Product Application
Pre-certification/pre-authorization review applies to all
psychological and neuropsychological testing for members in fully
insured and self-insured benefit plans. Pre-certification/preauthorization
review for psychological and neuropsychological
testing is not required for members in the following plans:
Blue Advantage (PMAP) programs
MinnesotaCare programs
Minnesota Senior Care Plus (MSC+)
SecureBlue (HMO SNP)
Platinum Blue (Cost)
MedicareBlue PPO (Regional PPO)
Medicare supplement
Code Narrative Units Practitioner General Policies
96101 Psychological testing
(includes psychodiagnostic
assessment of emotionality,
intellectual abilities,
personality and
psychopathology, e.g.,
MMPI, Rorschach, WAIS),
per hour of the
psychologist’s or
physician’s time, both faceto-face
time with the patient
and time interpreting test
results and preparing the
report.
Report one (1)
unit per hour
of face-to-face
testing,
interpretation
and
preparation of
report.
MD, LP-
PhD, LP-
MA
The psychologist
or psychiatrist
administers and
interprets the
test(s) and prepares
the report.
Billed under the
MD, LP-PhD, LP-
MA individual
provider number or
NPI.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12

Coding Policies and Guidelines (Behavioral Health)
Code Narrative Units Practitioner General Policies
96102 Psychological testing
(includes psychodiagnostic
assessment of emotionality,
intellectual abilities,
personality and
psychopathology, e.g.,
MMPI and WAIS), with
qualified health care
professional interpretation
and report, administered by
technician, per hour of
technician time, face-toface.
96103 Psychological testing
(includes psychodiagnostic
assessment of emotionality,
intellectual abilities,
personality and
psychopathology, e.g.,
MMPI), administered by a
computer, with qualified
health care professional
interpretation and report.
Report one (1)
unit per hour
of face-to-face
testing.
Report one (1)
unit per testing
session
regardless of
the number of
tests taken.
MD, LP-
Ph.D., LP-
MA,
LICSW,
CNS-Psych,
LMFT,
LPCC
MD, LP-
Ph.D., LP-
MA,
LICSW,
CNS-Psych,
PMHNP,
LMFT, NP,
PA, LPCC
A technician under
direct supervision,
administers the
test(s).
The supervising
qualified licensed
practitioner
interprets the
test(s) and prepares
the report.
Billed under the
supervising
licensed
practitioner
provider number or
NPI.
Patient is alone and
is taking a
computer-based
test.
A qualified
licensed
practitioner
interprets the
test(s) and prepares
the report.
Billed under the
licensed
practitioner
provider number or
NPI.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12 11-33

Coding Policies and Guidelines (Behavioral Health)
Code Narrative Units Practitioner General Policies
96116 Neurobehavioral status
exam (clinical assessment of
thinking, reasoning and
judgment, e.g., acquired
knowledge, attention,
language, memory, planning
and problem solving, and
visual spatial abilities), per
hour of the psychologist’s
or physician’s time, both
face-to-face time with the
patient and time interpreting
test results and preparing
the report.
96118 Neuropsychological testing
(e.g., Halstead-Reitan
neuropsychological battery,
Wechsler memory scales
and Wisconsin card sorting
test), per hour of the
psychologist’s or
physician’s time, both faceto-face
time with the patient
and time interpreting test
results and preparing the
report.
11-34
Report one (1)
unit per hour
of face-to-face
testing,
interpretation
and
preparation of
report.
Report one (1)
unit per hour
of face-to-face
testing,
interpretation
and
preparation of
report.
MD, LP-
PhD., LP-
MA,
LICSW,
CNS-Psych,
PMHNP,
LMFT, NP,
PA, LPCC
MD, LP-
PhD, LP-
MA
The psychologist
or psychiatrist
administers and
interprets the
test(s) and prepares
the report.
Billed under the
practitioner’s
individual provider
number or NPI.
The psychologist
or psychiatrist
administers and
interprets the
test(s) and prepares
the report.
Billed under the
MD, LP-PhD, LP-
MA individual
provider number or
NPI.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12

Coding Policies and Guidelines (Behavioral Health)
Code Narrative Units Practitioner General Policies
96119 Neuropsychological testing
(e.g., Halstead-Reitan
neuropsychological battery,
Wechsler memory scales
and Wisconsin card sorting
test), with qualified health
care professional
interpretation and report
administered by technician,
per hour of technician time,
face-to-face.
96120 Neuropsychological testing
(e.g., Wisconsin card
sorting test), administered
by a computer, with
qualified health care
professional interpretation
and report.
Report one (1)
unit per hour
of face-to-face
testing.
Report one (1)
unit per testing
session
regardless of
the number of
tests taken.
MD, LP-
PhD, LP-
MA
MD, LP-
PhD, LP-
MA
A technician,
under direct
supervision,
administers the
test(s).
The supervising
qualified licensed
practitioner
interprets the
test(s) and prepares
the report
Billed under the
supervising
licensed
practitioner
provider number or
NPI.
Patient is alone and
is taking a
computer-based
test.
A qualified
licensed
practitioner
interprets the
test(s) and prepares
the report.
Billed under the
licensed
practitioner
provider number or
NPI.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12 11-35

Coding Policies and Guidelines (Behavioral Health)
Code Narrative Units Practitioner General Policies
96125 Standardized cognitive
performance testing (e.g.,
Ross information processing
assessment) per hour of a
qualified health care
professional's time, both
face-to-face time
administering tests to the
patient and time interpreting
these test results and
preparing the report
11-36
Report one (1)
unit per hour
of face-to-face
testing,
interpretation
and
preparation of
report
MD, LP-
PhD, LP-
MA
The psychologist
or psychiatrist
administers and
interprets the
test(s) and prepares
the report.
Billed under the
MD, LP-PhD, LP-
MA individual
provider number or
NPI.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12

Practitioner Key MD = Psychiatrist
Coding Policies and Guidelines (Behavioral Health)
LP-Ph.D. = Licensed Psychologist, Doctorate
LP-MA = Licensed Psychologist, Masters
LICSW = Licensed Clinical Social Worker
CNS-Psych = Clinic Nurse Specialist, Psychiatric Specialty
PMHNP = Psychiatric Mental Health Nurse Practitioner
LMFT = Licensed Marriage and Family Therapist
PA = Physician Assistant
NP = Nurse Practitioner
LPC = Licensed Professional Counselor (ineligible provider,
unless practicing as part of a Rule 29 licensed clinic, a
community health center or a behavioral health clinic per the
Blue Cross criteria)
LPCC = Licensed Professional Clinical Counselor (ineligible
provider, unless practicing as part of a Rule 29 licensed clinic,
a community health center or a behavioral health clinic per the
Blue Cross criteria)
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12 11-37

Coding Policies and Guidelines (Behavioral Health)
Policies Policies applicable to the codes on the previous pages:
11-38
Test result interpretation and report preparation are an inherent
part of the testing service and are not separately billable. Only
one testing code may be billed.
Only a licensed psychologist or other licensed health care
professional may bill for these psychological and
neuropsychological tests.
The date of service submitted should be the date the testing is
completed, regardless of when the report is completed.
Testing, scoring, and interpretation done solely by a computer
is not a billable service.
There is no specific definition of technician; a technician may
be a psychometrist, student or trainee. Testing administered by
a technician may be billed if the service is rendered under
direct supervision of a qualified practitioner and if submitted
under the supervising practitioner’s individual provider number
or NPI.
Direct supervision definition: The physician/qualified
practitioner must be present in the same office (although not
necessarily in the same room as the non-physician/qualified
practitioner) and must be immediately available to assist and
direct throughout the performance of the service. A
physician/qualified practitioner cannot provide direct or
personal supervision via telemedicine.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12

Clinical Supervision
Under Minnesota Rule
Part 9505.0371 -
MHCP Members Only
Coding Policies and Guidelines (Behavioral Health)
Blue Cross requires clinical supervision to comply with Minnesota
Rule part 9505.0371 which was adopted and implemented on June
28, 2011. Refer to the Minnesota Department of Human Services
(DHS) Bulletin #11-53-03 for requirements related to clinical
supervision.
The Rule addresses standards in the following areas:
Eligibility of a supervisor
Eligibility of a supervisee
Individual and group supervision
Clinical supervision plan for each person under supervision
Documentation of a supervision session
When clinical supervision documentation is required in a
client’s chart
Blue Cross will continue to allow clinical supervision that meets
the requirement of the new Rule to be done in the following clinic
settings:
Rule 29 Licensed Clinics
Community Mental Health Centers
Behavioral Health Clinics as defined by Blue Cross
Mental Health Designated Essential Community Providers
Multi-specialty Clinics
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12 11-39

Coding Policies and Guidelines (Behavioral Health)
DIAMOND Initiative Blue Cross is participating in a collaborative effort along with the
Minnesota Department of Human Services (DHS) and other health
plans in Minnesota called the Depression Improvement Across
Minnesota, Offering a New Direction (DIAMOND) Initiative. The
DIAMOND Initiative collaborative is organized by the Institute for
Clinical Systems Improvement (ICSI). The goal of the DIAMOND
Initiative is to improve care for people who have depression by
providing services through a new care model offered in select
primary care settings.
11-40
Provider Participation
The DIAMOND Initiative will be offered at select primary care
settings that have been approved to participate by ICSI and have
been trained in the DIAMOND care model. The DIAMOND care
model includes adding a care manager and consulting psychiatrist
to the patient's treatment team. Blue Cross will be contacting the
select primary care providers who have been approved to
participate by ICSI and have been trained in the DIAMOND care
model.
Services and Billing
Approved providers should bill using HCPCS code T2022 (case
management, per month), billed as one unit per calendar month, on
a professional claim format (837P). This code will include any
services rendered by the care manager, the consultative time the
primary care physician/psychiatrist spends with the care manager,
and any non-face-to-face time the physician spends reviewing,
managing or coordinating care on behalf of the patient. Services
need to be billed on a monthly basis to the health plan that insured
the patient at the beginning of the month in which service
occurred. The provider should bill this code on a monthly basis for
a maximum of 12 consecutive months or until the member opts out
of the DIAMOND Initiative, whichever comes first.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12

DIAMOND Initiative
(continued)
Reimbursement
Coding Policies and Guidelines (Behavioral Health)
Only those primary care providers who have been certified or
approved by ICSI, who have been trained in the DIAMOND care
model, who have been contacted by Blue Cross, and who have
elected to participate in the DIAMOND Initiative will be eligible
for reimbursement. The Blue Cross allowed amount will be up to
$100 plus applicable MinnesotaCare tax for eligible members and
eligible providers up to a maximum of 12 consecutive months per
member.
Marital Counseling Diagnosis code V61.10, counseling for marital and partner
problems, unspecified.
Generally, marital counseling is a contract exclusion for
members and will deny as member responsibility when this
diagnosis code is used as the primary diagnosis. Relationship
improvement/enhancement services or training not related to
the treatment of a diagnosable mental health disorder are
generally not covered.
Opioid Maintenance
Drug Therapy
Opioid treatment will be processed at the member’s highest
benefit level if there is coverage for these services in the
member’s contract benefits. No referral is required for Blue
Plus members. If a member’s contract has no substance abuse
benefits or if a member’s contract has methadone and/or
buprenorphine treatment as a contract exclusion, then there is
no coverage for these services.
Only providers that are contracted as a freestanding methadone
clinic can bill methadone treatment services.
The participating freestanding opioid treatment clinics
methadone administration is a professional service that should
be billed on an 837P claim format with procedure code H0020
and diagnosis code 304.01. This charge will deny if incorrectly
submitted on an 837I. This service is treated as medication
management so will not be counted against any substance
abuse accumulation maximums for the member.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12 11-41

Coding Policies and Guidelines (Behavioral Health)
Opioid Maintenance
Drug Therapy
(continued)
11-42
Buprenorphine administration is a professional service that
should be billed on an 837P claim format. This charge will
deny if incorrectly submitted on an 837I. When administered
as part of a program, procedure code H0047 (along with a
narrative stating this is for buprenorphine) should be billed
with diagnosis code 304.01. When administered in the office,
the appropriate office visit or evaluation management
procedure code should be billed with diagnosis code 304.01.
Buprenorphine administration applies to the member’s
substance abuse benefits for office visits, and these charges
will not be applied to any accumulation maximums for the
member. The injectable form of buprenorphine hydrochloride
should be billed as code J0592 with one unit per 0.1 mg
dosage.
Tobacco Cessation Submit diagnosis code 305.1 or V15.82 if the intent is
counseling and/or visit to obtain a prescription for smoking
cessation medication/patches.
If linked to an E/M service, a preventative or general illness
benefit will be applied depending on the member’s benefits.
Do not use 305.1 or V15.82 as the primary diagnosis if the
member has a primary behavioral health diagnosis (such as
depression) that is being treated but the member also uses
tobacco. If this is the case, 305.1 or V15.82 should be listed as
a secondary diagnosis.
Hypnotherapy (code 90880), biofeedback (codes 90875-
90876), and acupuncture (codes 97810- 97811, 97813-97814)
are considered investigative for treatment of tobacco use,
dependence, and withdrawal, and are ineligible for
reimbursement.
Nicotine replacement therapies and bupropion for the treatment
of tobacco dependence are subject to the member’s pharmacy
benefits.
Coverage for the treatment of tobacco dependence is subject to
the member’s contract benefits.
Any inpatient treatment service for tobacco cessation should be
prior authorized, as they will be reviewed for medical
necessity.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12

Coding Policies and Guidelines (Behavioral Health)
Rule 29 Setting State licensed Rule 29 clinics will have three provider numbers:
Day Treatment H2012
One for services in the clinic
One for MD/Psychiatrists to bill for inpatient services
One for Ph.D. level psychologists to bill for inpatient services
Services should be billed under the appropriate provider number or
NPI.
Rule 29 clinics can only provide outpatient mental health services
under this licensure. Any inpatient services billed under the Rule
29 clinic provider number or NPI will be denied. Some Rule 29
clinics will also be licensed as nonresidential chemical dependency
providers. It is important to keep these two entities separate.
If a patient is being treated for depression secondary to a chemical
dependency, the depression diagnosis should be billed as the
primary diagnosis under the Rule 29 clinic provider number or
NPI.
When non-licensed practitioners treat patients, their services
MUST be billed under the supervising practitioner’s individual
provider number and with the U7 modifier or NPI.
Behavioral health day treatment services may be provided at a
licensed Rule 29 facility. Day treatment is a specific
programmatic service where the patient attends a minimum of
3 hours per day and generally 3-5 hours per day, 3-5 days per
week. The services provided within these hours may include
group therapy, living/social skills building groups, educational
groups, and some individual time.
Day treatment is billed as a program, rather than under an
individual provider. Bill one line for each day and one unit for
each hour the patient attends the program.
Services are reimbursed under the member’s outpatient mental
health benefits.
Compatibility This is a very common and frequent cause for claim denials. The
diagnosis code and CPT code must be compatible as well as
compatible with the practitioner’s licensure.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12 11-43

Coding Policies and Guidelines (Behavioral Health)
Health and Behavior
Assessment and
Intervention Codes
11-44
96150-96155
Codes 96150-96155 are eligible to be billed by all behavioral
health practitioners. However, per CPT, 96150-96155 describe
services offered to patients who present with established illnesses
or symptoms, are not diagnosed with mental illness, and may
benefit from evaluations that focus on biopsychological factors
related to the patients’ physical health status. The primary
diagnosis for the claim line containing these assessment and
intervention codes should be a non-behavioral health diagnosis
code. (An example would be a newly diagnosed cancer patient or a
patient struggling with infertility.)
Missed Appointments Missed scheduled appointments are not paid for by Blue Cross.
Blue Cross recommends that your clinic establish a uniform
cancellation policy requiring 24-hour advance notification. Your
clinic may bill a patient who misses a scheduled behavioral health
appointment, provided that you have notified the member in
writing in advance that this is your policy. A copy of this signed
notification should be maintained in your patient’s medical record.
Your patient should be billed no more than your contracted rate.
Government programs such as Prepaid Medical Assistance
(PMAP), MinnesotaCare and Medicare prohibit billing for missed
appointments.
This policy applies to providers, whose scope of practice is
behavioral health, including psychiatrists, licensed psychologists
(LP), licensed independent clinical social workers (LICSW),
licensed marriage and family therapists (LMFT), registered nurse
clinical specialist (CNS) and out-patient chemical dependency
(OPCD) facilities. This policy change is not intended to apply to
medication management provided within the member’s primary
care clinic or internist’s office.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12

Missed Appointments
(continued)
Court Ordered
Treatment
Coding Policies and Guidelines (Behavioral Health)
Blue Cross expects behavioral health providers to abide by the
following guidelines:
PMAP, MinnesotaCare and Medicare members cannot be
charged for missed appointments.
Providers must establish a reasonable business policy that
allows for patients not to be charged for failed appointments
due to circumstances outside of their control.
Providers must abide by guidelines established by the
American Medical Association (AMA) and the American
Psychological Association (APA), which state it is ethical for
providers to charge for missed appointments or for
appointments not canceled at least 24 hours in advance, if
patients have been fully advised of the possibility of such
charges.
When a court order for treatment is based on evaluation and
recommendation by a physician, licensed Ph.D. level psychologist,
licensed alcohol and drug dependency counselor, or a certified
chemical dependency assessor (Rule 25), Blue Cross will consider
the order medically necessary.
Blue Cross will provide coverage for these court ordered services
according to the patient’s contract benefits. For example, if the
member does not have inpatient chemical dependency benefits and
the patient is court ordered into inpatient chemical dependency
treatment, there will be no coverage for the services.
Participating providers should maintain a copy of the court order in
the patient’s chart. Nonparticipating providers should fax in the
evaluation and court order to Integrated Health Management at
(651) 662-0854 as soon as possible so that the necessary approval
can be entered into the claim system in time to ensure the claim is
paid accurately.
If the court order specifies a certain non-network provider but the
member does not have any benefits for non-network providers,
Blue Cross will cover the services as they would for any other
network provider. However, fee-for-service members will be
responsible for the difference between the billed amount and Blue
Cross’ allowed amount.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12 11-45

Coding Policies and Guidelines (Behavioral Health)
Guidelines for Court
Ordered Evaluations
11-46
An appropriately licensed physician or Ph.D. level psychologist
must perform the mental health assessment. A physician, licensed
alcohol and drug dependency counselor, or certified chemical
dependency assessor must perform the chemical dependency
assessment.
The following services are eligible for Blue Cross coverage
(subject to the terms of the member's contract):
Mental health evaluations/diagnostic assessments and related
testing
Chemical health evaluations
72 hour holds under the Mental Health Act, Minn. Stat.
253B.05
24-hour mental health observation beds
Mental health evaluations to determine the need for civil
commitment for treatment
Submitting Mental and/or Chemical Health Court Ordered
Evaluations
Blue Cross recognizes that certain court ordered evaluations may
be lengthy and wants to ensure equitable reimbursement to
providers for these types of evaluations, but the claim submission
must be HIPAA compliant including the restriction of units based
on the code narrative. Behavioral health assessments/evaluations
are reported under code 90801. Only one unit of service may be
submitted regardless of the time spent with the patient. To alert
Blue Cross that this is a court ordered evaluation, an H9 modifier
must be appended to 90801. Prior authorization is not required;
however, the court order for the evaluation must be on file in the
patient’s medical record.
Court Ordered Evaluation Claim Submission Guideline
HCPCS code: 90801
HCPCS modifier: H9 (court ordered)
Unit: one unit (regardless of time spent)
Diagnosis code: appropriate ICD-9-CM mental or chemical
health diagnosis
Coverage of follow-up care will depend upon individual member
benefits.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12

Guidelines for Court
Ordered Evaluations
(continued)
Coding Policies and Guidelines (Behavioral Health)
The following are Blue Cross guidelines regarding Mental
Health Evaluation components: (from Blue Cross Behavioral
Health Guidelines for Treatment Record Documentation
previously sent to providers by Blue Cross Quality Improvement.)
The assessment or mental status exam is to identify appropriate
subjective and objective information pertinent to the patient's
presenting complaint. The presenting symptoms are to be
clearly identified with the onset, duration and intensity
documented.
The assessment contains the patient's presenting problem(s) as
well as relevant psychological or social conditions affecting the
patient's medical or psychiatric status. For children and
adolescents (18 and under), past medical history and
psychiatric history includes prenatal and perinatal events and a
complete developmental history (physical, psychological,
social, intellectual, and academic).
The mental status exam is to document the patient's affect,
speech, mood, thought content, judgment, insight, attention or
concentration, memory, impulse control, suicidal ideation and
homicidal ideation.
For patients 10 years and older, there is to be an appropriate
notation in the assessment concerning past and present use of
tobacco, alcohol, as well as illicit, prescribed and over-thecounter
substances.
Past medical/behavioral history is easily identifiable in the
record and includes, if applicable; previous treatment dates,
former provider information, therapeutic interventions and
responses, source of clinical data, relevant family information,
results of lab test and consultation reports.
To determine if a comprehensive substance abuse evaluation is
needed, a substance abuse screening is to be incorporated into
the assessment of all new patients. This can be accomplished
by the use of brief questionnaires such as CAGAID or the
AUDIT.
The provider is to have procedures in place for the reassessment
of patients who return for treatment after having
been out of treatment for an extended period of time.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12 11-47

Coding Policies and Guidelines (Behavioral Health)
Guidelines for Court
Ordered Evaluations
(continued)
11-48
The MH evaluation components of the following assessments are
eligible for Blue Cross coverage (subject to the terms of the
member's contract):
Civil competency evaluations (evaluation to guide courts in
determining whether a person is mentally competent to manage
his/her own affairs)
Competency and diminished capacity evaluations (evaluation
to guide courts in determining whether to award guardianship
of an adult)
Domestic violence assessments
Pre-placement assessments (for evaluation prior to county
placement in various settings, which may include foster care,
shelter care, residential treatment, corrections, etc.)
Sex offender evaluations (does not cover the criminal history
review or risk assessment portions as identified in MN Rule
2955.0100, Subp.7. A, B, C, D, G and J)
Sex offender evaluations (SOE) performed for forensic
(court ordered) purposes are not reimbursed and will be
denied as subscriber liability.
SOE performed as part of treatment is eligible for separate
reimbursement. Submit 90899 (unlisted psychiatric service
or procedure) with medical records. Coverage and/or
liability will be determined based on review and purpose of
the evaluation.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12

Guidelines for Court
Ordered Evaluations
(continued)
Guidelines for Court
Ordered Evaluations –
Noncovered Services
Coding Policies and Guidelines (Behavioral Health)
Blue Cross does not cover forensic evaluations conducted to
answer specific legal questions.
Forensic Evaluations
In contrast to a mental health evaluation, a forensic evaluation is
conducted primarily to assist the legal system in making decisions
regarding family, civil or criminal matters. In these instances, the
summary and conclusions relate directly to the legal issues, and the
relationship between psychological factors and the legal issues are
described. (For more information go to
www.psychologyinfo.com/forensic/index.html, a link provided
through the American Psychological Association website.)
It is our expectation that a MH professional conducting one of the
following assessments will use his/her clinical judgment. In the
event that the MH professional determines that the member
requires a MH evaluation as a component of one of these
evaluations for the purpose of identifying and determining
treatment needs, Blue Cross will consider the component eligible
for coverage, subject to the terms of the member's contract.
The following are examples of forensic evaluations that are not
covered by Blue Cross:
Adoption home studies (evaluation to guide courts in decision
whether to allow adoption of children by an individual or
couple)
Adoption readiness evaluations (evaluation to guide courts in
decisions regarding adoption placement planning)
Adult pre-sentencing evaluations (evaluation to guide courts in
determining sentencing of adults in criminal matters)
Assessment of emotional factors in sexual harassment and
discrimination (evaluation to guide courts decision regarding
sexual harassment and/or discrimination)
Child abuse evaluations, including sexual abuse evaluations
(investigative evaluation to determine presence and/or extent
of child physical and/or sexual abuse)
Child custody evaluations (evaluations to guide the courts
decision in determining who should have custody of minor
children)
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12 11-49

Coding Policies and Guidelines (Behavioral Health)
Guidelines for Court
Ordered Evaluations –
Noncovered Services
(continued)
11-50
Criminal competency evaluations (evaluation to determine
whether a person is competent to stand trial)
Development of family reunification plans (service to guide
courts decisions regarding child placement/return to family
setting)
Education classes for DUI offenses (education classes/program
regarding driving under the influence. A CD diagnosis is not
required for attendance.)
Evaluating the credibility of child witnesses (evaluation to
guide courts in determining credibility of a child witness)
Evaluations of juveniles accused of criminal acts (evaluation to
guide courts in determining whether a minor should be tried as
an adult)
Evaluations to assess termination of parental rights (evaluation
to guide courts decision regarding termination of parental
rights)
Juvenile pre-sentencing evaluations (evaluation to guide courts
decision related to sentencing in criminal matters)
Juvenile probation evaluations (evaluation to guide courts
decision related to probation terms in criminal matters)
Mediation of parental conflicts about children (service to
provide assistance to parents engaged in a legal dispute over
child custody and/or visitation)
Parenting assessments/parental competency evaluation
(evaluation to guide the courts decisions about parental rights,
custody and placements)
Personal injury evaluations (evaluation to guide courts decision
in awarding damages related to personal injury)
Visitation risk assessments (evaluations to guide the courts
decision in determining child visitation rights; may include
grandparent visitation.)
Workers’ compensation evaluations (evaluation to determine
extent of damage related to a workers’ compensation claim)
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12

Coding Policies and Guidelines (Behavioral Health)
Parity Federal laws and state mandates dictate mental health parity laws
that are applicable to all fully insured groups. Self-insured groups
are not subject to parity laws and legislation unless they choose to
add this benefit.
Behavioral Health
Quality Improvement
Objectives
Parity means that treatment for substance abuse and/or mental
health is covered the same as any other inpatient and/or outpatient
medical benefit. For example, if a member has coverage for an
illness E/M service from a non-network provider, then that
member will also have coverage for a behavioral health service
from a non-network provider.
Based upon results of the 2004 quality improvement activities and
National Committee for Quality Assurance (NCQA) standards,
Blue Cross requires participation from behavioral health providers
in the following activities:
Follow-up After Hospitalization for Mental Illness
Offer appointments to new and returning patients within seven
days of mental health hospitalization discharge. Appointments
should be provided within the timeframe commensurate with
patient clinical need. Blue Cross recommends that behavioral
health providers develop an appointment scheduling strategy to
accommodate newly discharged patients, if they have not already
done so.
Standardized Substance Abuse Screenings in Mental Health
Assessments
Routinely utilize standardized substance abuse screening
questionnaires (e.g., CAGEAID) in mental health assessments
for new patients age 12 and older. (Routine substance use
assessment of children ages 10 and 11 is also recommended.)
Recommend or refer patients for comprehensive substance
abuse assessment based on the screening results and
corroborating clinical information from the substance use
assessment.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12 11-51

Coding Policies and Guidelines (Behavioral Health)
Behavioral Health
Quality Improvement
Objectives (continued)
11-52
Exchange of Information with Primary Care Physicians
Routinely ask all new patients to authorize exchange of
information with primary care/specialty physicians.
Establish a distinct section in the treatment record, if one does
not exist, dedicated to case management activities. This section
should contain:
Documentation of patient authorization/refusal to exchange
information with the physician.
When authorized, documentation of communication with
the physician (e.g., report, letter, telephone or e-mail
communication).
When recommending a patient seek psychopharmacologic
treatment from his/her primary care physician or if the
patient’s primary care physician recommended mental
health assessment and/or treatment, provide the primary
care physician with the current behavioral health
diagnosis(es), diagnostic criteria (i.e., symptoms with
onset, duration and severity) and treatment plan, if
applicable.
When authorized, the treating psychiatrist or clinical
nurse specialist should provide the current diagnosis
(es) and initial medication management information to
the primary care/specialty physician. This requirement
is important for patient safety.
Appointment Accessibility
Provide routine initial appointments within ten business days
of the request.
Provide routine follow-up appointments within ten business
days of the initial appointment.
Provide urgent appointments within 24 hours of the request.
Provide non-life-threatening-emergency appointments within
six hours of the request.
Provide or facilitate life-threatening-emergency care
immediately.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12

Behavioral Health
Quality Improvement
Objectives (continued)
Coding Policies and Guidelines (Behavioral Health)
Questions, comments or material requests should be directed to:
Attn: Mary Rains R4-18
Blue Cross and Blue Shield of Minnesota and Blue Plus
P.O. Box 64179
St. Paul, MN 55164-0179
Phone: (651) 662-0826 or 1-800-382-2000 x20826
Fax: (651) 662-3625
E-mail: mary_e_rains@bluecrossmn.com
Prior Authorization Blue Cross does not usually require prior authorization for
outpatient mental health or chemical dependency services provided
within the Select or Aware ® provider networks, depending on
specific contract requirements. Likewise, if the patient has benefits
for behavioral health services from a non-network provider, no
prior authorization is usually required. If the patient does NOT
have benefits for behavioral health services from a non-network
provider, there is no coverage and claims will deny as “not
covered.”
A few groups do have specific prior authorization requirements for
behavioral health services. Contact provider services for a specific
group’s requirements:
Phone: 1-800-262-0820 or (651) 662-5200
Fax: (651) 662-2745
Federal Employee Program ® (FEP) (member ID numbers begin
with “R”) members require a prior authorization for all outpatient
mental health and substance abuse services before the first visit.
To request a prior authorization, complete the Minnesota universal
outpatient mental/chemical health authorization form that is
available on bluecrossmn.com. Select “for health care providers”
then “forms and publications” and in the drop down box, select
“forms: prior authorization.” If you have questions regarding FEP
members:
Phone: (651) 662-5044 or 1-800-859-2128
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12 11-53

Coding Policies and Guidelines (Behavioral Health)
Prior Authorization
(continued)
11-54
Providers may use the following numbers to submit a prior
authorization request, check on the status of a prior authorization
request, or ask questions about prior authorization guidelines for
Behavioral Health Services.
Phone: 1-800-262-0820
Fax: (651) 662-0854 outpatient or inpatient behavioral health
services
Providers should submit a new prior authorization request when
requesting additional services or a change in dates of service for a
prior authorization.
Referrals Blue Cross does not require a referral for patients seeking care
within the Select Behavioral Health Network. For complete
information on requirements for Minnesota Health Care Programs,
see Chapter 3 of the Blue Plus Manual.
Preadmission
Notification
Services sought outside the Select Behavioral Health Network but
within the Aware network will be processed according to the
patient’s self-referral benefit, if the patient’s contract has a selfreferral
benefit. If the patient has specialty needs, continuity of
care issues, transition of care issues, or cannot access behavioral
health services within the required provider network within a
reasonable time period, or due to geographical or physical
accessibility reasons, the provider should contact Blue Cross and
request a referral. A referral will be approved depending on the
patient’s situation.
If services are sought outside both the Select network and the
Aware network and the member does not have self-referral
benefits, then Blue Cross should be contacted and the situation
reviewed for a possible referral approval.
Call (651) 662-2474 or 1-800-262-0820 or fax form X13459 to
(651) 662-0856 to notify Blue Cross of admissions into day
treatment, partial psychiatric or inpatient programs.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12

Pre-certification and
Concurrent Review for
Inpatient/Residential
Mental Health and
Substance use
Disorder Services
Coding Policies and Guidelines (Behavioral Health)
To help assure that members receive the appropriate level of care
for mental health and substance use disorder treatment, Blue
Cross, as done with other medical/surgical services, require certain
pre-certification and concurrent review protocols for
inpatient/residential services.
This program will continue to expand and impacted providers will
receive additional information once these requirements are
expanded.
Pre-certification and concurrent review applies to health services
provided to members in fully insured and self-insured benefit
plans, including Minnesota Health Care Programs, with the
exception of Minnesota Senior Care Plus (MSC+), SecureBlue
(HMO SNP), Platinum Blue (Cost) and MedicareBlue PPO
(Regional PPO) members. Medicare supplement benefit plans are
also excluded from review. This also does not apply to court
ordered admissions to inpatient/residential treatment. Coverage for
court ordered mental health services is detailed in Minnesota
Statute 62Q.535.
Definitions
"Pre-certification" is defined as an advance review of a proposed
facility admission or certain services or procedures in order to
determine whether the proposed admission, services or procedures
meet the medical necessity criteria for payment and to ensure that
the subscriber receives the maximum benefits available under the
subscriber’s plan.
"Concurrent review" is defined as ongoing review during the
subscriber’s care to ensure that it meets established medical
criteria in a timely manner and certifies the necessity, the
appropriateness and quality of services during an inpatient
admission.
Pre-certification Requirements
Provider will obtain pre-certification from Blue Cross before
admitting a member. If admission is emergent or after business
hours, provider will obtain pre-certification within two (2)
business days after the admission.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12 11-55

Coding Policies and Guidelines (Behavioral Health)
Pre-certification and
Concurrent Review for
Inpatient/Residential
Mental Health and
Substance use
Disorder Services –
(continued)
Groups that Carve Out
Behavioral Health
Benefits
11-56
Provider shall obtain pre-certification by calling Blue Cross at
(651) 662 5270 or toll free at 1-800-528-0934. Blue Cross will use
criteria set forth in the Level of Care Utilization System (LOCUS)
and Child and Adolescent Services Intensity Instrument (CASII)
for mental health or the Dimensions criteria for substance use
disorders in conducting a medical necessity review for the
admission.
Failure to provide evidence of medical necessity may result in
claim denials as provider liability.
Concurrent Review Requirements
Providers have a contractual obligation as noted in Chapter 4 of
the online Blue Cross Provider Policy and Procedure Manual to
adhere to care management programs. At the time of precertification
a date will be established to conduct concurrent
review.
Concurrent review will include verification of medical necessity
based on criteria set forth in the LOCUS and CASII for mental
health or the Dimensions criteria for substance use disorders.
Failure to provide evidence of medical necessity may result in
claim denials as provider liability.
Some self-insured contract with another carrier to manage their
behavioral health benefits. This means that their behavioral health
claims should be filed to the designated third party behavioral
health carrier for processing. This carrier’s information should be
obtained from the patient.
E/M services (codes 99201-99215) and medication management
services (codes 90862 or M0064) billed with a behavioral health
diagnosis for carve out group members should be billed to Blue
Cross as long as the practitioner is a non-behavioral health
practitioner or a multi-specialty clinic. If one of these services is
denied, Blue Cross should be contacted for it to be reprocessed.
These services will be paid at the behavioral health benefit but will
not accumulate towards patients’ behavioral health benefit
maximums. Any other behavioral health treatment for carve out
group members that is billed to Blue Cross will be denied.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12

Coding Policies and Guidelines (Behavioral Health)
Provider Networks There are two behavioral health provider networks: the Select
Behavioral Health Network and the Aware network.
Most Blue Plus patients are required to utilize a Select provider for
their highest level of benefits. Many but not all members have selfreferral
benefits that are applied when services are obtained in the
Aware network. To find a participating Select network provider,
members are encouraged to call Blue Cross so that a provider best
suited to meet their treatment needs can be found in a convenient
location.
The majority of fee-for-service members have direct access to an
Aware network practitioner.
Fully insured groups have the Select Behavioral Health Network.
Some self-insured groups have the Select Behavioral Health
Network while other self-insured groups may choose the Aware
Network. Individual accounts use the Aware Network.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12 11-57

Professional Behavioral Health Coding Information
Blue Cross and Blue Shield of Minnesota and Blue Plus
Code Description Units Who May Submit Misc
90801 Psychiatric diagnostic interview exam 1 per session MD, LP-PhD., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, LPCC
90802 Interactive diagnostic interview exam 1 per session MD, LP-Ph.D., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, LPCC
90804 Individual psychotherapy, insight oriented,
office/outpatient, 20-30 min.
90805 Individual psychotherapy, insight oriented,
office/outpatient, 20-30 min., w/E/M
90806 Individual psychotherapy, insight oriented,
office/outpatient, 45-50 min.
90807 Individual psychotherapy, insight oriented,
office/outpatient, 45-50 min., w/E/M
90808 Individual psychotherapy, insight oriented,
office/outpatient, 75-80 min.
90809 Individual psychotherapy, insight oriented,
office/outpatient, 75-80 min., w/E/M
90810 Individual psychotherapy, interactive,
office/outpatient, 20-30 min.
90811 Individual psychotherapy, interactive,
office/outpatient, 20-30 min., w/E/M
90812 Individual psychotherapy, interactive,
office/outpatient, 45-50 min.
1 per session MD, LP-Ph.D., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, LPCC
1 per session MD, CNS-Psych, PMHNP
1 per session MD, LP-Ph.D., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, LPCC
1 per session MD, CNS-Psych, PMHNP
1 per session MD, LP-Ph.D., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, LPCC
1 per session MD, CNS-Psych, PMHNP
1 per session MD, LP-Ph.D., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, LPCC
1 per session MD, CNS-Psych, PMHNP
1 per session MD, LP-Ph.D., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, LPCC
Coding Policies and Guidelines (Behavioral Health)
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12 11-59

Coding Policies and Guidelines (Behavioral Health)
Code Description Units Who May Submit Misc
90813 Individual psychotherapy, interactive,
office/outpatient, 45-50 min., w/E/M
90814 Individual psychotherapy, interactive,
office/outpatient, 75-80 min.
90815 Individual psychotherapy, interactive,
office/outpatient, 75-80 min., w/E/M
90816 Individual psychotherapy, insight oriented,
inpatient, 20-30 min.
90817 Individual psychotherapy, insight oriented,
inpatient, 20-30 min., w/E/M
90818 Individual psychotherapy, insight oriented,
inpatient, 45-50 min.
90819 Individual psychotherapy, insight oriented,
inpatient, 45-50 min., w/E/M
90821 Individual psychotherapy, insight oriented,
inpatient, 75-80 min.
90822 Individual psychotherapy, insight oriented,
inpatient, 75-80 min., w/E/M
90823 Individual psychotherapy, interactive,
inpatient, 20-30 min.
90824 Individual psychotherapy, interactive,
inpatient, 20-30 min., w/E/M
90826 Individual psychotherapy, interactive,
inpatient, 45-50 min.
11-60
1 per session MD, CNS-Psych, PMHNP
1 per session MD, LP-Ph.D., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, LPCC
1 per session MD, CNS-Psych, PMHNP
1 per session MD, LP-Ph.D., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, LPCC
1 per session MD, CNS-Psych, PMHNP
1 per session MD, LP-Ph.D., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, LPCC
1 per session MD, CNS-Psych, PMHNP
1 per session MD, LP-Ph.D., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, LPCC
1 per session MD, CNS-Psych, PMHNP
1 per session MD, LP-Ph.D., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, LPCC
1 per session MD, CNS-Psych, PMHNP
1 per session MD, LP-Ph.D., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, LPCC
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12

Code Description Units Who May Submit Misc
90827 Individual psychotherapy, interactive,
inpatient, 45-50 min., w/E/M
90828 Individual psychotherapy, interactive,
inpatient, 75-80 min.
90829 Individual psychotherapy, interactive,
inpatient, 75-80 min., w/E/M
1 per session MD, CNS-Psych, PMHNP
1 per session MD, LP-Ph.D., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, LPCC
1 per session MD, CNS-Psych, PMHNP
Coding Policies and Guidelines (Behavioral Health)
90845 Psychoanalysis 1 per session MD only Not covered – may be a
contract exclusion
90846 Family psychotherapy (without patient
present)
1 per session MD, LP-Ph.D., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, LPCC
90847 Family psychotherapy (with patient present) 1 per session MD, LP-Ph.D., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, LPCC
90849 Multiple family group psychotherapy 1 per session MD, LP-Ph.D., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, LPCC
90853 Group psychotherapy (other than family) 1 per session MD, LP-Ph.D., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, LPCC
90857 Interactive group psychotherapy 1 per session MD, LP-Ph.D., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, LPCC
90862 Pharmacologic management w/minimal
psychotherapy
90865 Narcosyntheseis for psychiatric diagnostic
and therapeutic purposes (e.g., sodium
amobarbital (amytal) interview)
May be a contract
exclusion. Incompatible
with non-BH dx
Incompatible with non-BH
dx
Incompatible with non-BH
dx
Incompatible with non-BH
dx
Incompatible with non-BH
dx
1 per session MD, CNS-Psych, PMHNP, PA, NP Incompatible with non-BH
dx
1 per session MD, CNS-Psych, PMHNP Incompatible with non-BH
dx
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12 11-61

Coding Policies and Guidelines (Behavioral Health)
Code Description Units Who May Submit Misc
90870 Electroconvulsive therapy; (includes
necessary monitoring)
90875 Individual psychophysiological therapy
incorporating biofeedback, 20-30 min.
90876 Individual psychophysiological therapy
incorporating biofeedback, 45-50 min.
11-62
1 per day MD only Incompatible with non-BH
dx
1 per session MD, LP-Ph.D., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, LPCC
1 per session MD, LP-Ph.D., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, LPCC
90880 Hypnotherapy 1 per session MD, LP-Ph.D., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, LPCC
90882 Environmental intervention for medical
management purposes
1 per session MD, LP-Ph.D., LP-MA, LICSW, CNS-
Psych, LMFT, LPCC
Incompatible with non-BH
dx
Incompatible with non-BH
dx
Incompatible with non-BH
dx
Not covered - incl. in basic
service (for Public Program
members, allowed for
ARHMS program)
90885 Psychiatric evaluation of hospital records 1 per day MD only Not covered - incl. in basic
service
90887 Interpretation or explanation of exam results 1 per day MD, LP-Ph.D., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, LPCC
90889 Preparation of report of patient’s psychiatric
status
90899 Unlisted psychiatric service or procedure 1 unit- submit
time
Not covered - incl. in basic
service
1 per service MD only Not covered - contract
exclusion
MD, LP-Ph.D., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, LPCC
Submit narrative and time
90901 Biofeedback training by any modality 1 per session MD only Not covered in home POS-
contract exclusion
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12

Code Description Units Who May Submit Misc
90911 Biofeedback training, perineal muscles,
anorectoal or urethral sphincter, including
EMG and/or manometry
96101 Psychological testing, (includes
psychodiagnostic assessment of emotionality,
intellectual abilities, personality and
psychopathology, e.g., MMPI, Rorschach,
WAIS), per hour of the psychologist’s or
physician’s time, both face-to-face time
administering tests to the patient and time
interpreting test results and preparing the
report
96102 Psychological testing (includes
psychodiagnostic assessment of emotionality,
intellectual abilities, personality and
psychopathology, e.g., MMPI and WAIS),
with qualified health care professional
interpretation and report, administered by
technician, per hour of technician time, faceto-face
Coding Policies and Guidelines (Behavioral Health)
1 per session MD only Not covered in home POS-
contract exclusion
1 unit per hour
of face-to-face
testing,
interpretation
and
preparation of
report
Report 1 unit
per hour of
face-to-face
testing
MD, LP-Ph.D., LP-MA The psychologist or
psychiatrist administers
and interprets the test(s)
and prepares the report.
Billed under the MD, LP-
PhD, LP-MA individual
provider number or NPI.
MD, LP-PhD, LP-MA, LICSW, CNS-
Psych, LMFT, LPCC
A technician under direct
supervision, administers
the test(s). The supervising
qualified licensed
practitioner interprets the
test(s) and prepares the
report. Billed under the
supervising licensed
practitioner provider
number or NPI.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12 11-63

Coding Policies and Guidelines (Behavioral Health)
Code Description Units Who May Submit Misc
96103 Psychological testing (includes
psychodiagnostic assessment of emotionality,
intellectual abilities, personality and
psychopathology, e.g., MMPI), administered
by a computer, with qualified health care
professional interpretation and report
96116 Neurobehavioral status exam (clinical
assessment of thinking, reasoning and
judgment, e.g., acquired knowledge, attention,
language, memory, planning and problem
solving, and visual spatial abilities), per hour
of the psychologist’s or physician’s time, both
face-to-face time with the patient and time
interpreting test results and preparing the
report
96118 Neuropsychological testing (e.g., Halstead-
Reitan neuropsychological battery, Wechsler
memory scales and Wisconsin card sorting
test), per hour of the psychologist’s or
physician’s time, both face-to-face time
administering tests to the patient and time
interpreting test results and preparing the
report
11-64
Report 1 unit
per testing
session
regardless of
number of tests
MD, LP-PhD, LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, NP, PA, LPCC
1 per hour MD, LP-PhD., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, NP, PA, LPCC
Report 1 unit
per hour of
face-to-face
testing,
interpretation
and
preparation of
report
Patient is alone and taking
a computer-based test.
A qualified licensed
practitioner interprets the
test(s) and prepares the
report.
Billed under the licensed
practitioner provider
number or NPI.
MD, LP-Ph.D., LP-MA The psychologist or
psychiatrist administers
and interprets the test(s)
and prepares the report.
Billed under the MD, LP-
PhD, LP-MA individual
provider number or NPI.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12

Code Description Units Who May Submit Misc
96119 Neuropsychological testing (e.g., Halstead-
Reitan neuropsychological battery, Wechsler
memory scales and Wisconsin card sorting
test), with qualified health care professional
interpretation and report, administered by
technician, per hour of technician time, faceto-face
96120 Neuropsychological testing (e.g., Wisconsin
card sorting test), administered by a
computer, with qualified health care
professional interpretation and report
96125 Standardized cognitive performance testing
(e.g., Ross information processing
assessment) per hour of a qualified health care
professional's time, both face-to-face time
administering tests to the patient and time
interpreting these test results and preparing
the report
Report 1 unit
per hour of
face-to-face
testing
Report 1 unit
per testing
session
regardless of
number of tests
Report 1 unit
per hour of
face-to-face
testing,
interpretation
and
preparation of
report
Coding Policies and Guidelines (Behavioral Health)
MD, LP-PhD, LP-MA A technician under direct
supervision, administers
the test(s). The supervising
qualified licensed
practitioner interprets the
test(s) and prepares the
report. Billed under the
supervising licensed
practitioner provider
number or NPI.
MD, LP-PhD, LP-MA Patient is alone and is
taking a computer-based
test. A qualified licensed
practitioner interprets the
test(s) and prepares the
report. Billed under the
licensed practitioner
provider number or NPI.
MD, LP-PhD, LP-MA The psychologist or
psychiatrist administers
and interprets the test(s)
and prepares the report.
Billed under the MD, LP-
PhD, LP-MA individual
provider number or NPI.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12 11-65

Coding Policies and Guidelines (Behavioral Health)
Code Description Units Who May Submit Misc
96150 Health and behavior assessment (e.g., healthfocused
clinical interview, behavioral
observations, psychophysiological
monitoring, health-oriented questionnaires),
each 15 minutes face-to-face with the patient;
initial assessment
96151 Health and behavior assessment (e.g., healthfocused
clinical interview, behavioral
observations, psychophysiological
monitoring, health-oriented questionnaires),
each 15 minutes face-to-face with the patient;
re-assessment
96152 Health and behavior intervention, each 15
minutes, face-to-face; individual
96153 Health and behavior intervention, each 15
minutes, face-to-face; group (2 or more
patients)
96154 Health and behavior intervention, each 15
minutes, face-to-face; family (with the patient
present)
96155 Health and behavior intervention, each 15
minutes, face-to-face; family (without the
patient present)
11-66
1 per 15
minutes
1 per 15
minutes
1 per 15
minutes
1 per 15
minutes
1 per 15
minutes
1 per 15
minutes
MD, LP-Ph.D., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, NP, PA, LPCC
MD, LP-Ph.D., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, NP, PA, LPCC
MD, LP-Ph.D., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, NP, PA, LPCC
MD, LP-Ph.D., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, NP, PA, LPCC
MD, LP-Ph.D., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, NP, PA, LPCC
MD, LP-Ph.D., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, NP, PA, LPCC
MH/CD diagnosis is NOT
primary diagnosis
MH/CD diagnosis is NOT
primary diagnosis
MH/CD diagnosis is NOT
primary diagnosis
MH/CD diagnosis is NOT
primary diagnosis
MH/CD diagnosis is NOT
primary diagnosis
MH/CD diagnosis is NOT
primary diagnosis
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12

Code Description Units Who May Submit Misc
98960 Education and training for patient selfmanagement
by a qualified, nonphysician
health care professional using a standard
curriculum, face-to-face with the patient
(could include caregiver/family) each 30
minutes; individual patient
98961 Education and training for patient selfmanagement
by a qualified, nonphysician
health care professional using a standardized
curriculum, face-to-face with the patient
(could include caregiver/family) each 30
minutes; 2-4 patients
98962 Education and training for patient selfmanagement
by a qualified, nonphysician
health care professional using a standardized
curriculum, face-to-face with the patient
(could include caregiver/family) each 30
minutes; 5-8 patients
99201-
99205
99211-
99215
99217-
99220
1 per 30
minutes
1 per 30
minutes
1 per 30
minutes
MD, LP-PhD., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, NP, PA, LPCC
MD, LP-Ph.D., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, NP, PA, LPCC
MD, LP-PhD., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, NP, PA, LPCC
Office or other outpatient E/M – new patient 1 per visit MD, NP, CNS, CNS-psych, PMHNP, PA
Coding Policies and Guidelines (Behavioral Health)
Limited coverage for:
PMAP/MNCare
Diabetes dx
BH dx
Prenatal
Limited coverage for:
PMAP/MNCare
Diabetes dx
BH dx
Prenatal
Limited coverage for:
PMAP/MNCare
Diabetes dx
BH dx
Prenatal
Office or other outpatient E/M – established
patient
1 per visit MD, NP, CNS, CNS-psych, PMHNP, PA
Hospital observation services, initial 1 per visit MD, NP, CNS, CNS-psych, PMHNP, PA Routine dx not allowed
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12 11-67

Coding Policies and Guidelines (Behavioral Health)
Code Description Units Who May Submit Misc
99221-
99223
99224-
99226
99231-
99233
99234-
99236
11-68
Hospital inpatient E/M – initial 1 per visit MD, NP, CNS, CNS-psych, PMHNP, PA,
Approved Mental Health Clinic,
Community Mental Health Center,
Essential Community Provider
Routine dx not allowed
Hospital observation services; subsequent 1 per visit MD, NP, CNS, CNS-psych, PMHNP, PA Routine dx not allowed
Hospital inpatient E/M – subsequent 1 per visit MD, CNS-Psych, NP, PA, CNS, PMHNP,
Approved Mental Health Clinic,
Community Mental Health Center,
Essential Community Provider
Observation or inpatient hospital care 1 per day MD, NP, CNS, CNS-psych, PMHNP, PA,
Approved Mental Health Clinic,
Community Mental Health Center,
Essential Community Provider
99238 Hospital discharge, 30 minutes or less 1 per day MD, Approved Mental Health Clinic,
CNS-Psych, NP, PA, CNS, PMHNP,
Community Mental Health Center,
Essential Community Provider
99239 Hospital discharge, more than 30 minutes 1 per day MD, Approved Mental Health Clinic,
CNS-Psych, NP, PA, CNS, PMHNP,
Community Mental Health Center,
Essential Community Provider
99241-
99245
99251-
99255
Office or other outpatient consultation 1 per session MD only
Inpatient consultation, initial 1 per session MD only
Routine dx not allowed
Routine dx not allowed
Routine dx not allowed
Routine dx not allowed
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12

Code Description Units Who May Submit Misc
99281-
99285
Emergency department E/M 1 per session MD only
99408 Alcohol and/or substance (other than tobacco)
abuse structured screening (e.g., AUDIT,
DAST), and brief intervention (SBI) services;
15 to 30 minutes
99409 Alcohol and/or substance (other than tobacco)
abuse structured screening (e.g., AUDIT,
DAST), and brief intervention (SBI) services;
greater than 30 minutes
G0175 Scheduled interdisciplinary team conference
(minimum of three exclusive of patient care
nursing staff) with patient present
G0176 Activity therapy, such as music, dance, art or
play therapies not for recreation, related to the
care and treatment of patient’s disabling
mental health problems, per session (45
minutes or more)
G0177 Training and educational services related to
the care and treatment of patient’s disabling
mental health problems per session (45
minutes or more)
1 per session MD, LP-PhD, LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, LPCC
1 per session MD, LP-PhD, LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, LPCC
Coding Policies and Guidelines (Behavioral Health)
Compatible with alcohol or
substance abuse dx only.
Compatible with alcohol or
substance abuse dx only.
1 per session N/A Denied. If IP or partial
hospital - part of hospital
rates. Not payable as OP
therapy code – no medical
necessary care is provided.
1 per session N/A Denied. If IP or partial
hospital - part of hospital
rates. Not payable as OP
therapy code – no medical
necessary care is provided.
1 per session N/A Denied. If IP or partial
hospital - part of hospital
rates. Not payable as OP
therapy code – no medical
necessary care is provided.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12 11-69

Coding Policies and Guidelines (Behavioral Health)
Code Description Units Who May Submit Misc
G0396 Alcohol and/or substance (other than tobacco)
abuse structured assessment (e.g., AUDIT,
DAST), and brief intervention 15 to 30
minutes
G0397 Alcohol and/or substance (other than tobacco)
abuse structured assessment (e.g., AUDIT,
DAST), and intervention, greater than 30
minutes
G0409 Social work and psychological services,
directly relating to and/or furthering the
patient's rehabilitation goals, each 15 minutes,
face-to-face; individual (services provided by
a CORF-qualified social worker or
11-70
psychologist in a CORF)
G0410 Group psychotherapy other than of a
multiple-family group, in a partial
hospitalization setting, approximately 45 to
50 minutes
G0411 Interactive group psychotherapy, in a partial
hospitalization setting, approximately 45 to
50 minutes
G9012 Other specified case management service not
otherwise classified
1 per session MD, LP-PhD, LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, Rule 25, LPCC
1 per session MD, LP-PhD, LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, Rule 25, LPCC
1 per 15
minutes
MD, LP-PhD., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, LPCC
1 per session MD, LP-PhD., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, LPCC
1 per session MD, LP-PhD., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, LPCC
1 per session
MD, LP-PhD., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, LPCC
H0001 Alcohol and/or drug assessment 1 per session MD, LP-Ph.D., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, Rule 25, LPCC
H0002 Behavioral health screening to determine
eligibility for admission to treatment program
1 per session MD, LP-Ph.D., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, LPCC
Compatible with alcohol or
substance abuse dx only.
Compatible with alcohol or
substance abuse dx only.
Incompatible with non-BH
dx
Incompatible with non-BH
dx
Incompatible with non-BH
dx
Autism related service only
Compatible with alcohol or
substance abuse dx only.
Compatible with alcohol or
substance abuse dx only.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12

Code Description Units Who May Submit Misc
H0003 Alcohol and/or drug screening; laboratory
analysis of specimens for presence of alcohol
and/or drugs
H0004 Behavioral health counseling and therapy, per
15 minutes
H0005 Alcohol and/or drug services; group
counseling by a clinician
H0006 Alcohol and/or drug services; case
management
H0007 Alcohol and/or drug services; crisis
intervention (outpatient)
H0008 Alcohol and/or drug services; sub-acute
detoxification (hospital inpatient)
H0009 Alcohol and/or drug services; acute
detoxification (hospital inpatient)
H0010 Alcohol and/or drug services; sub-acute
detoxification (residential addiction program
inpatient)
H0011 Alcohol and/or drug services; acute
detoxification (residential addiction program
inpatient)
H0012 Alcohol and/or drug services; sub-acute
detoxification (residential addiction program
outpatient)
1 per session MD, LP-Ph.D., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, LPCC
1 per 15
minutes
MD, LP-Ph.D., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, LPCC
1 per session MD, LP-Ph.D., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, LPCC
1 per session MD, LP-Ph.D., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, LPCC
1 per session MD, LP-Ph.D., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, LPCC, mobile
crisis provider specialty, Rule 29.
1 per session MD, CNS-Psych, PMHNP, NP, PA, CNSmedical
1 per session MD, CNS-Psych, PMHNP, NP, PA, CNSmedical
1 per session MD, CNS-Psych, PMHNP, NP, PA, CNSmedical
1 per session MD, CNS-Psych, PMHNP, NP, PA, CNSmedical
1 per session MD, CNS-Psych, PMHNP, NP, PA, CNSmedical
Coding Policies and Guidelines (Behavioral Health)
Compatible with alcohol or
substance abuse dx only.
Incompatible with non-BH
dx
Compatible with alcohol or
substance abuse dx only.
Non-covered
Compatible with alcohol or
substance abuse dx only.
Compatible with alcohol or
substance abuse dx only.
Compatible with alcohol or
substance abuse dx only.
Compatible with alcohol or
substance abuse dx only.
Compatible with alcohol or
substance abuse dx only.
Compatible with alcohol or
substance abuse dx only.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12 11-71

Coding Policies and Guidelines (Behavioral Health)
Code Description Units Who May Submit Misc
H0013 Alcohol and/or drug services; acute
detoxification (residential addiction program
outpatient)
H0014 Alcohol and/or drug services; ambulatory
detoxification
H0015 Alcohol and/or drug services; intensive
outpatient (treatment program that operates at
least 3 hours/day and at least 3 days/week and
is based on an individualized treatment plan),
including assessment, counseling; crisis
intervention, and activity therapies or
education
H0016 Alcohol and/or drug services;
medical/somatic (medical intervention in
ambulatory setting)
H0017 Behavioral health; residential (hospital
residential treatment program), without room
and board, per diem
H0018 Behavioral health; short-term residential
(non-hospital residential treatment program),
without room and board, per diem
H0019 Behavioral health; long-term residential (nonmedical,
non-acute care in residential
treatment program where stay is typically
longer than 30 days), without room and board,
per diem
11-72
1 per session MD, CNS-Psych, PMHNP, NP, PA, CNSmedical
1 per session MD, CNS-Psych, PMHNP, NP, PA, CNSmedical
1 per session MD, LP-PhD., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, LPCC
1 per session MD, CNS-Psych, PMHNP, PA, NP, CNS-
Medical
1 per day/diem MD, LP-PhD., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, LPCC
Compatible with alcohol or
substance abuse dx only.
Compatible with alcohol or
substance abuse dx only.
Compatible with alcohol or
substance abuse dx only.
Compatible with alcohol or
substance abuse dx only.
Compatible with mental
health dx only.
1 per day/diem IRTS Crisis provider Compatible with mental
health dx only.
1 per day/diem IRTS Crisis provider Compatible with mental
health dx only.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12

Code Description Units Who May Submit Misc
H0020 Alcohol and/or drug services; methadone
administration and/or service (provision of the
drug by a licensed program)
H0021 Alcohol and/or drug training service (for staff
and personnel not employed by providers)
H0022 Alcohol and/or drug intervention service
(planned facilitation)
H0023 Behavioral health outreach service (planned
approach to reach a target population)
H0024 Behavioral health prevention information
dissemination service (one-way direct or nondirect
contact with service audiences to affect
knowledge or attitude)
H0025 Behavioral health prevention education
service (delivery of services with target
population to affect knowledge, attitude
and/or behavior)
H0026 Alcohol and/or drug prevention process
service, community-based (delivery of
services to develop skills of impactors)
1 per session Freestanding Methadone/Opiod clinic,
Substance Abuse Facility
Coding Policies and Guidelines (Behavioral Health)
1 per session N/A Not covered
1 per session N/A Not covered
1 per session N/A Not covered
1 per session N/A Not covered
1 per session N/A Not covered
1 per session N/A Not covered
Covered when provided
within a methadone clinic
or substance abuse facility.
Compatible with alcohol or
substance abuse dx only.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12 11-73

Coding Policies and Guidelines (Behavioral Health)
Code Description Units Who May Submit Misc
H0027 Alcohol and/or drug prevention
environmental service (broad range of
external activities geared toward modifying
systems in order to mainstream prevention
through policy and law)
H0028 Alcohol and/or drug prevention problem
identification and referral service(e.g. student
assistance and employee assistance
programs), does not include assessment
H0029 Alcohol and/or drug prevention alternatives
service (services for populations that exclude
alcohol and other drug use, e.g. alcohol free
social events)
11-74
1 per session N/A Not covered
1 per session N/A Not covered
1 per session N/A Not covered
H0030 Behavioral health hotline service 1 per session N/A Not covered
H0031 Mental health assessment, by non-physician 1 per session LP-Ph.D., LP-MA, LICSW, CNS-Psych,
PMHNP, LMFT, NP, PA, behavioral
health therapist, LPCC
H0032 Mental health service plan development by
non-physician
H0034 Medication training and support, per 15
minutes
H0035 Mental health partial hospitalization,
treatment, less than 24 hours
1 per session N/A Not covered
1 per 15
minutes
Behavioral health clinic, MD, LP-Ph.D.,
LP-MA, LICSW, CNS-Psych, LMFT,
LPCC
Generally not covered –
eligible coding for
ARMHS – Public
Program/MNCare only
1 per day Rule 29, approved mental health clinic Compatible with BH dx
only
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12

Code Description Units Who May Submit Misc
H0036 Community psychiatric supportive treatment,
face-to-face, per 15 minutes
H0037 Community psychiatric supportive treatment
program, per diem
1 per 15
minutes
H0038 Self-help/peer services, per 15 minutes 1 per 15
minutes
H0039 Assertive community treatment, face-to-face,
per 15 minutes
H0040 Assertive community treatment program, per
diem
H0046 Mental health services, not otherwise
specified
H0047 Alcohol and/or other drug abuse services, not
otherwise specified
H0048 Alcohol and/or other drug testing: collection
and handling only, specimens other than
blood
Coding Policies and Guidelines (Behavioral Health)
N/A Not covered
1 per day N/A Not covered
1 per 15
minutes
N/A Generally not covered –
may be allowed for PMAP
only
N/A Not covered
1 per day MD, LP-Ph.D., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, behavioral health
clinic, BH Therapist Practitioner, LPCC
1 per day / 1
minute for
travel time
1 unit – submit
time
1 per service
MD, LP-Ph.D., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, behavioral health
clinic, BH Therapist Practitioner, LPCC
PMAP only
PMAP only – use for travel
time for In-Home services.
Requires narrative.
Freestanding methadone/opioid clinic Requires narrative and
time.
MD, LP-PhD., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT
H0049 Alcohol and/or drug screening 1 per service MD, LP-Ph.D., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, LPCC
H0050 Alcohol and/or drug services, brief
intervention, per 15 minutes
1 per 15
minutes
MD, LP-Ph.D., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, LPCC
Compatible with alcohol or
substance abuse dx only
Compatible with alcohol or
substance abuse dx only.
Compatible with alcohol or
substance abuse dx only.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12 11-75

Coding Policies and Guidelines (Behavioral Health)
Code Description Units Who May Submit Misc
H2001 Rehabilitation program, per ½ day 1 per day MD, LP-Ph.D., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, PA, NP, LPCC
H2010 Comprehensive medication services, per 15
minutes
11-76
1 per 15
minutes
H2011 Crisis intervention service, per 15 minutes 1 per 15
minutes
MD, CNS-Psych, PMHNP, PA, NP
MD, LP-Ph.D., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, PA, NP,
behavioral health clinic, LPCC
H2012 Behavioral health day treatment, per hour 1 per hour MD, LP-Ph.D., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, PA, NP, LPCC
PMAP only
H2013 Psychiatric health facility service, per diem 1 per day N/A Not covered
H2014 Skills training and development, per 15
minutes
H2015 Comprehensive community support services,
per 15 minutes
H2016 Comprehensive community support services,
per diem
H2017 Psychosocial rehabilitation services, per 15
minutes
1 per 15
minutes
1 per 15
minutes
MD, LP-Ph.D., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, PA, NP, LPCC
MD, LP-Ph.D., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, PA, NP, LPCC
Incompatible with non-BH
dx
PMAP or autism related
service only
PMAP/MNCare only.
Submit UA modifier for
crisis intervention.
1 per day N/A Not covered
1 per 15
minutes
Behavioral health clinic, MD, LP-Ph.D.,
LP-MA, LICSW, CNS-Psych, LMFT,
LPCC
H2018 Psychosocial rehabilitation services, per diem 1 per day N/A Not covered
Generally not covered –
may be allowed for Public
Program/ MNCare for
ARHMS or autism related
service only
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12

Code Description Units Who May Submit Misc
H2019 Therapeutic behavioral services, per 15
minutes
1 per 15
minutes
MD, LP-Ph.D., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, PA, NP, LPCC
H2020 Therapeutic behavioral services, per diem 1 per day MD, LP-Ph.D., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, PA, NP, LPCC
H2021 Community based wrap-around services, per
15 minutes
1 per 15
minutes
Coding Policies and Guidelines (Behavioral Health)
N/A Not covered
PMAP/MNCare or
autism related service
Modifier required:
UA modifier for
MH Behavioral
aide Level 1. HM
modifier for MH
Behavioral aide
Level 2. HE
modifier for MH
Practitioner
direction of MH
Behavioral aide.
PMAP/MNCare only
Modifier required:
UA modifier for
MH Behavioral
aide Level 1. HM
modifier for MH
Behavioral aide
Level 2. HE
modifier for MH
Practitioner
direction of MH
Behavioral aide.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12 11-77

Coding Policies and Guidelines (Behavioral Health)
Code Description Units Who May Submit Misc
H2022 Community based wrap-around services, per
diem
H2023 Supported employment, per 15 minutes 1 per 15
minutes
11-78
1 per day N/A Not covered
N/A Not covered
H2024 Supported employment, per diem 1 per day N/A Not covered
H2025 Ongoing support to maintain employment, per
15 minutes
H2026 Ongoing support to maintain employment, per
diem
1 per 15
minutes
H2027 Psychoeducational service, per 15 minutes 1 per 15
minutes
H2028 Sexual offender treatment, per 15 minutes 1 per 15
minutes
N/A Not covered
1 per day N/A Not covered
MD, LP-PhD, LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, PA, NP, LPCC
MD, LP-Ph.D., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, PA, NP, LPCC,
Certified Residential Sex Offender
Treatment Facility
H2029 Sexual offender treatment, per diem 1 per day MD, LP-Ph.D., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, PA, NP, LPCC,
Certified Residential Sex Offender
Treatment Facility
H2030 Mental health clubhouse services, per 15
minutes
1 per 15
minutes
MD, LP-Ph.D., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, PA, NP, LPCC
H2031 Mental health clubhouse services, per diem 1 per day MD, LP-Ph.D., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, PA, NP, LPCC
Compatible with bipolar
disorder, schizophrenia,
and BPD dx only.
Not allowed with 90801
Not allowed with 90801
Not covered
Not covered
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12

Code Description Units Who May Submit Misc
H2032 Activity therapy, per 15 minutes 1 per 15
minutes
MD, LP-Ph.D., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, PA, NP, LPCC
Coding Policies and Guidelines (Behavioral Health)
Not covered
H2033 Multisytemic therapy for juveniles 1 per session N/A Generally not covered
H2034 Alcohol and/or drug abuse halfway house
services, per diem
H2035 Alcohol and/or other drug treatment program,
per hour
H2036 Alcohol and/or other drug treatment program,
per diem
H2037 Developmental delay prevention activities,
dependent child of client, per 15 minutes
M0064 Brief office visit for monitoring or changing
drug prescriptions
S3005 Performance measurement, evaluation of
patient self assessment, depression
1 per day N/A Not covered
1 per hour N/A Not covered
1 per day N/A Not covered
1 per 15
minutes
N/A Not covered
1 per session MD, CNS-Psych, PMHNP, PA, NP Compatible with BH dx
only
1 per session N/A Not covered
S8940 Equestrian/hippotherapy, per session 1 per session N/A Not covered
S9475 Ambulatory setting substance abuse treatment
or detoxification services, per diem
S9480 Intensive outpatient psychiatric services, per
diem
S9482 Family stabilization services, per 15 minutes 1 per 15
minutes
1 per day MD, LP-Ph.D., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, LPCC
1 per day MD, LP-Ph.D., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, PA, NP, LPCC
Compatible with CD dx
only
Compatible with BH dx
only
N/A Not covered
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12 11-79

Coding Policies and Guidelines (Behavioral Health)
Code Description Units Who May Submit Misc
S9484 Crisis intervention mental health services, per
hour
S9485 Crisis intervention mental health services, per
diem
T1006 Alcohol and/or substance abuse services,
family/couple counseling
T1007 Alcohol and/or substance abuse services,
treatment plan development and/or
modification
T1009 Child sitting services for children of the
individual receiving alcohol and/or substance
abuse services
11-80
1 per hour Rule 29, Mobile Crisis, MD, LP-Ph.D.,
LP-MA, LICSW, CNS-Psych, PMHNP,
LMFT, PA, NP, LPCC, approved mental
health clinic, behavioral health clinic
Applicable modifiers:
HM – less than
bachelor’s degree level
HN – bachelor’s degree
level
HQ – group setting
UA – non-MD
professional
Child/Adolescent
practitioner
1 per diem Rule 29, Mobile Crisis Applicable modifiers:
1 per session MD, LP-Ph.D., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, PA, NP, LPCC
UA – for MH
professional
Child/Adolescent
practitioner.
HN – BA level
practitioner.
Compatible with CD dx
only
1 per session N/A Not covered
1 per session N/A Not covered
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12

Code Description Units Who May Submit Misc
T1010 Meals for individual receiving alcohol and/or
substance abuse services (when meals not
included in the program)
T1012 Alcohol and/or substance abuse services,
skills development
T1023 Screening to determine the appropriateness of
consideration of an individual for
participation in a specified program, project
or treatment protocol, per encounter
T1024 Evaluation and treatment by an integrated,
specialty team contracted to provide
coordinated care to multiple or severely
handicapped children, per encounter
T1025 Intensive, extended multidisciplinary services
provided in a clinic setting to children with
complex medical, physical, mental and
psychosocial impairments, per diem
T1026 Intensive, extended multidisciplinary services
provided in a clinic setting to children with
complex medical, physical, medical and
psychosocial impairments per hour
T1027 Family training and counseling for child
development, per 15 minutes
T1028 Assessment of home, physical and family
environment, to determine suitability to meet
patient's medical needs
Coding Policies and Guidelines (Behavioral Health)
1 per day N/A Not covered
1 per session N/A Not covered
1 per session MD, LP-PhD., LP-MA, LICSW, CNS-
Psych, PMHNP, LMFT, PA, NP, LPCC,
Community Mental Health Center, Rule
29, Essential community provider, BH
clinic
1 per session N/A Not covered
1 per day N/A Not covered
1 per hour N/A Not covered
1 per 15
minutes
N/A Not covered
1 per session N/A Not covered
Autism related service only
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12 11-81

Coding Policies and Guidelines (Behavioral Health)
Code Description Units Who May Submit Misc
T1029 Comprehensive environmental lead
investigation, not including laboratory
analysis, per dwelling
T2010 Preadmission screening and resident review
(PASRR) level I identification screening, per
screen
T2011 Preadmission screening and resident review
(PASRR) level II evaluation, per evaluation
11-82
1 per session N/A Not covered
1 per screen N/A Not covered
1 per
evaluation
N/A Not covered
T2012 Habilitation, educational; waiver, per diem 1 per day N/A Not covered
T2013 Habilitation, educational, waiver; per hour 1 per hour N/A Not covered
T2014 Habilitation, prevocational, waiver; per diem 1 per day N/A Not covered
T2015 Habilitation, prevocational, waiver; per hour 1 per hour N/A Not covered
T2016 Habilitation, residential, waiver; per diem 1 per day N/A Not covered
T2017 Habilitation, residential, waiver; 15 minutes 1 per 15
minutes
T2018 Habilitation, supported employment, waiver;
per diem
T2019 Habilitation, supported employment, waiver;
per 15 minutes
N/A Not covered
1 per day N/A Not covered
1 per 15
minutes
N/A Not covered
T2020 Day habilitation, waiver; per diem 1 per day N/A Not covered
T2021 Day habilitation, waiver; per 15 minutes 1 per 15
minutes
N/A Not covered
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12

Code Description Units Who May Submit Misc
T2022 Case management, per month 1 per calendar
month
T2023 Targeted case management; per month 1 per calendar
month
T2024 Service assessment/ plan of care
development, waiver
T2025 Waiver services; not otherwise specified
(NOS)
Coding Policies and Guidelines (Behavioral Health)
N/A Generally not covered
Approved MH Center, BH Clinic,
Community MH Center, CNS – Psych,
LICSW, LP-PhD, LP – MA, LMFT,
PMHNP, LPCC, Social Service Agency
DIAMOND project only
PMAP/MNCare only
1 per session N/A Not covered
1 per session N/A Not covered
T2026 Specialized childcare, waiver; per diem 1 per day N/A Not covered
T2027 Specialized childcare, waiver; per 15 minutes 1 per 15
minutes
T2028 Specialized supply, not otherwise specified,
waiver
T2029 Specialized medical equipment, not otherwise
specified, waiver
T2030 Assisted living; waiver, per month 1 per calendar
month
N/A Not covered
1 per session N/A Not covered
1 per session N/A Not covered
N/A Not covered
T2031 Assisted living; waiver, per diem 1 per day N/A Not covered
T2032 Residential care, not otherwise specified
(NOS), waiver; per month
T2033 Residential care, not otherwise specified
(NOS), waive; per diem
1 per calendar
month
N/A Not covered
1 per day N/A Not covered
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12 11-83

Coding Policies and Guidelines (Behavioral Health)
Code Description Units Who May Submit Misc
T2034 Crisis intervention, waiver; per diem 1 per day N/A Not covered
T2035 Utility services to support medical equipment
and assistive technology/ devices, waiver
T2036 Therapeutic camping, overnight, waiver; each
session
T2037 Therapeutic camping day, waiver; each
session
11-84
1 per session N/A Not covered
1 per session N/A Not covered
1 per session N/A Not covered
T2038 Community transition, waiver; per service 1 per session N/A Not covered
T2039 Vehicle modifications, waiver; per service 1 per session N/A Not covered
T2040 Financial management, self-directed, waiver;
per 15 minutes
T2041 Supports brokerage, self-directed, waiver; per
15 minutes
T2048 Behavioral health; long-term care residential
(non-acute care in a residential treatment
program where stay is typically longer than
30 days), with room and board, per diem
1 per 15
minutes
1 per 15
minutes
N/A Not covered
N/A Not covered
1 per day N/A Not covered
MD = Psychiatrist; LP-Ph.D. = Licensed Psychologist, Doctorate; LP-MA = Licensed Psychologist, Masters; LICSW = Licensed Clinical Social Worker; PA = Physician’s Assistant: NP = Nurse Practitioner, CNS-
Psych = Clinical Nurse Specialist, Psychiatric specialty; PMHNP = Psychiatric Mental Health Nurse Practitioner; LMFT = Licensed Marriage and Family Therapist
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12

Coding Policies and Guidelines (Behavioral Health)
Behavioral Health for Institutional (837I) Billers
Introduction This section of the manual is intended for all behavioral health
practitioners who bill on the 837I claim format. This section is not
intended for practitioners whose services are billed on the 837P
claim format.
Practitioners Who
Should be Using this
Section
Residential treatment centers, non-residential treatment centers,
Rule 5 facilities, Rule 8 facilities, hospitals, state hospitals and
treatment centers, freestanding detoxification centers, sex offender
treatment facilities.
Coding Guidelines Use the following codes for submitting behavioral health
evaluation or testing services on the 837I claim format.
Behavioral Health
Evaluation or Testing
Revenue
Code
HCPCS
Code Narrative Time Units
0914 90801 Psychiatric diagnostic
review
0914 90802 Interactive psychiatric
diagnostic interview
0918 96101-
96102
0918 96118-
96119
Psychological testing
per hour
Neuropsychological
testing battery with
interpretation or report
Per
session
Per
session
60
minutes
60
minutes
1 unit
1 unit
1 per
hour
1 per
hour
Units One or more units should be submitted based on the time
designation within the HCPCS code narrative. If there is no time
designation, the service is considered ‘per session’ and only one
unit should be submitted regardless of the actual time spent.
Unit guidelines are also noted in the appropriate following
sections.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12 11-85

Coding Policies and Guidelines (Behavioral Health)
Individual Behavioral
Health Therapy
Family and Group
Therapy
11-86
Revenue
Code
0911 See
HCPCS/
CPT for
approp.
code
HCPCS
Code Narrative Time Units
Psychiatric/
Psychological
service/rehabilitat
ion. Do not use
for CD services.
0912 H2012 Psychiatric/
Psychological
service/partial
hospitalization -
less intensive
0914 See CPT
codes for
individual
therapy
Psychiatric/
psychological
service/individual
therapy
Based on
HCPCS/
CPT
code
used
One line
for each
day the
patient
attends
the
program
Based on
CPT
code
used
Depends
on
HCPCS/
CPT code
used
1 unit for
each hour
the patient
attends
the
program
Depends
CPT code
used
Use these codes when billing behavioral health family and group
therapy services on an 837I claim format.
Revenue
Code
0915 See
HCPCS/
CPT
codes for
group
therapy
0916 90846 or
90847
0917 90875 or
90876
0918 96101-
96102,
96118-
96119
HCPCS
Code Narrative Time Units
Psychiatric/
Psychological
service/group
therapy
Psychiatric/
Psychological
service/family
therapy
Psychiatric/
psychological
service/
biofeedback
Psychiatric/
psychological
service/testing
Based on
HCPCS/
CPT
code
used
Per
session
Per
session
60
minute
code
Depends
on
HCPCS/
CPT code
used
One unit
per
session
One unit
per
session
One unit
per 60
minutes
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12

Substance Abuse
Services
Billing a Behavioral
Health Assessment
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12
Coding Policies and Guidelines (Behavioral Health)
The Minnesota Department of Health Minnesota Companion
Guide includes a table showing the correct reporting of substance
abuse services. See section A.5.3, Table 3, of the Minnesota
Uniform Companion Guide for Institutional Claims at the
following link
http://www.health.state.mn.us/auc/instguide.htm.
The table incorporates both institutional and professional claim
types for ease of reference.
0912, 0944 or 0945 with 90801 or 90802
Bill 0912 and 90801/90802 with a mental health, chemical
dependency or alcohol dependency diagnosis code
Bill 0944 and 90801/90802 with a chemical dependency
diagnosis code
Bill 0945 and 90801/90802 with an alcohol dependency
diagnosis
Testing 0918 with 96101-96103, 96118-96125
Family Therapy 0916 with 90846
Testing is compatible with all behavioral health diagnosis codes.
Revenue code 0916 and CPT 90846 is billed for family therapy
when the patient is not present. There may be specific contract
exclusions on for some self-insured groups.
Revenue code 0916 and CPT 90846 should be billed under the
specific patient, and not under the member.
Bill one unit per session, regardless of total time.
0916 with 90847
Revenue code 0916 and CPT 90847 is billed for family therapy
when the patient is present. There may be specific contract
exclusions for some self-insured groups.
Revenue code 0916 and CPT 90847 should be billed under the
specific patient, and not under the member.
Bill one unit per session, regardless of total time.
11-87

Coding Policies and Guidelines (Behavioral Health)
Nutritional
Counseling/
Dietitians
11-88
0942 with 97802-97804
Nutritional counseling is usually eligible if billed with either a
behavioral health diagnosis or with a medical diagnosis such as
obesity or diabetes. Group nutritional therapy services billed under
revenue code 0942 with CPT 97804 are generally only covered
when submitted with diagnosis codes for anorexia, bulimia,
diabetes, congestive heart failure, and some maternity diagnoses.
Obesity is not an eligible diagnosis for CPT 97804. Outpatient
hospital services billed with revenue code 0942 and procedure
codes 97802, 97803 or 97804 are eligible services. There are no
limits to the number of eligible services a patient receives if the
patient has a fully insured contract. In contrast, some self-insured
contracts may choose to apply contract variations/exclusions for
nutritional counseling services.
Registered dietitians and licensed nutritionists can bill
independently for procedure codes S9470, 97802, 97803 and
97804 when billed with eating disorder diagnoses 307.1, 307.50
and 307.51. No referral is required for the highest benefit level.
For all other diagnoses, licensed dietitian and nutritionist services
must be submitted to Blue Cross by an eligible medical clinic or
hospital. The individual provider number or NPI of the licensed
dietitian or nutritionist must be submitted on the claim. Claims for
registered dietitians billing services outside of behavioral health
diagnoses will deny unless the services are submitted under the
individual provider number or NPI of a supervising physician.
The contract for Federal Employee Program members (who have
ID numbers beginning with “R”) only allows medical nutrition
therapy services in the following situations: Dietitian assessments
as part of a multi-disciplinary eating disorder evaluation; and
medical nutrition therapy services as part of ongoing nutritional
therapy for eating disorders anorexia nervosa (diagnosis
code307.1) and/or bulimia nervosa (diagnosis code 307.51).
Coverage is extended to diabetic educators, dietitians and
nutritionists who bill independently as part of a covered diabetic
education program only. Nutritional counseling for up to four
visits per year is covered when billed by a covered provider,
although nutritional counseling for the treatment of anorexia and
bulimia billed with diagnosis codes 307.1 or 307.51 is not subject
to the four visit limitation. Outpatient hospital services billed with
revenue code 0942 and procedure codes 97802, 97803 and 97804
are eligible services.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12

Detox and
Alcohol/Drug Rehab
Services
Health and Behavior
Assessment and
Intervention Codes
0116, 0126, 0136, 0146, 0156
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12
Coding Policies and Guidelines (Behavioral Health)
Detox is a medically supervised treatment program for alcohol or
drug addiction designed to purge the body of intoxicating or
addictive substances. Detox is a medical service that treats
physiological issues. When during this detox process the patient is
not able to participate in a substance abuse treatment program,
detox services are payable out of medical benefits, not substance
abuse benefits. It would be appropriate to bill primary diagnosis
code 980.9 when submitting alcohol detox services. It would be
appropriate to bill primary diagnosis code 977.9 when submitting
chemical/drug detox services.
Bill one unit of service per night spent in a detox bed.
When billing therapy/treatment services such as revenue code
0944 (drug rehabilitation) or 0945 (alcohol rehabilitation,) a
chemical dependency or alcohol dependency diagnosis code
must be submitted. These services are payable out of substance
abuse benefits if the patient’s policy has substance abuse
benefits.
If a patient’s policy does not have a substance abuse benefit,
only room and board charges are eligible, typically billed under
revenue code 0126. Detox services will not be paid if billed in
conjunction with a therapy service such as revenue code 0944
or 0945.
If a patient’s policy does have a substance abuse benefit, then
both room and board and therapy charges are eligible.
Detox does not accumulate towards policy limitations.
Detoxification services are eligible when they are provided in a
state licensed freestanding detoxification center, a hospital or a
residential treatment center.
96150-96155
CPT codes 96150-96155 describe services offered to patients who
present with established illnesses or symptoms and who are not
diagnosed with mental illness. The primary diagnosis should be a
non-behavioral health diagnosis code. Codes 96150-96155 should
not be reported with revenue codes 0900-0919 on facility claims.
Codes 96150-96155 may be submitted under revenue code 0940.
11-89

Coding Policies and Guidelines (Behavioral Health)
Non-Residential
Treatment Centers
FEP Exclusion of
Residential Treatment
Centers
11-90
State licensed non-residential treatment centers generally only bill
outpatient chemical dependency services. A limited number of
mental health services will be covered in this setting.
Some non-residential treatment centers are dually licensed as both
a Rule 29 clinic and a residential treatment center. It is important
to bill appropriate services under each separate entity. Mixing
services and provider specialties may cause a claim to deny.
The Federal Employee Program (FEP) benefits specifically
exclude services billed or provided by a residential treatment
center (RTC). To access the 2011 Service Benefit Plan brochure
go to fepblue.org and the information is currently available on
pages 70 and 86 regarding the RTC exclusion. Affected providers
include all mental health and substance abuse RTCs.
All Federal Employee Program members have been notified that
RTCs are not covered providers. Blue Cross will work with these
members through the case management team to ensure they
continue to receive medically necessary and cost-effective
treatment.
Compatibility Compatibility is a frequent and common cause of claim denials.
Recreational Therapy 0941
Revenue code 0944 should only be billed with a chemical
dependency diagnosis code.
Revenue Code 0945 should only be billed with an alcohol
dependency diagnosis code.
Recreational therapy may be part of an approved CD outpatient
program. It is included under the CD program charges and should
not be billed separately under revenue code 0941.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12

Extended Care and
Halfway House Room
and Board (Medicaid
Government Programs
Only)
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12
Coding Policies and Guidelines (Behavioral Health)
Blue Plus is responsible for reimbursing providers for extended
care and halfway house services for our Minnesota Health Care
Program members. This applies only to the government programs
listed below.
To ensure that Blue Plus can accurately distinguish, adjudicate the
claim and report encounter data to the Minnesota Department of
Human Services (DHS), the room and board (R&B) charges for
extended care, halfway house and primary residential treatment,
must be submitted in the following manner:
Provider Type Type of Bill
Primary
residential
R&B Rev
Code
R&B Rev Code
Description
086X 1002 Behavioral
health
accommodation
– residential
treatment –
chemical
dependency
Extended care 086X 1003 Behavioral
health
accommodation
– supervised
living
Halfway house 086X 1004 Behavioral
health
accommodation
– halfway house
Treatment
Treatment should also be reported in addition to the appropriate
R&B codes noted above. Chemical dependency treatment is
reported using either revenue code 0944 (Drug rehabilitation) or
0945 (Alcohol rehabilitation).
11-91

Coding Policies and Guidelines (Behavioral Health)
Extended Care and
Halfway House Room
and Board (Medicaid
Government Programs
Only) (continued)
11-92
Blue Plus
Product Name Group Numbers
Blue Advantage –
PMAP
Blue Advantage –
GA/GAMC
Blue Advantage –
MSC+
PP011, PP012, PP014, PP015, PP016,
PP017, PP021, PP022, PP024, PP025,
PP026, PP027, PP031, PP032, PP034,
PP035, PP036, PP037
PP081, PP082, PP084, PP091, PP092, PP094
PP041, PP042, PP044, PP051, PP052,
PP054, PP055, PP056, PP057, PP061,
PP062, PP064, PP071, PP072, PP075,
PP076, PP077
MinnesotaCare PP161, PP162, PP163, PP164, PP121,
PP122, PP131, PP132, PP141, PP142,
PP111, PP112, PP151, PP152
SecureBlue PP200, PP201, PP202, PP210, PP220,
PP221, PP222, PP230, PP240, PP245,
PP250, PP255, PP260, PP261, PP262,
PP270, PP280, PP281, PP282, PP290, PP215
Fax a copy of the completed Rule 25 Assessment and Placement
Summary, available on line at dhs.state.mn.us admitting
diagnosis code for member, admitting physician/provider (if
applicable) and provider’s address.
Fax this information to:
Integrated Health Management-Chemical Dependency
Utilization Management (CD UM) (651) 662-0718.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12

Extended Care and
Halfway House Room
and Board (Medicaid
Government Programs
Only) (continued)
Partial Psychiatric
Billing
Admission Notification
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12
Coding Policies and Guidelines (Behavioral Health)
For Blue Plus members in the affected groups, please notify Blue
Plus of the member’s extended care or halfway house services by
faxing a copy of the following forms to (651) 662-0718:
Chemical Dependency Notification of Residential Admission
Form
Rule 25 Assessment and Placement Summary
The Chemical Dependency Notification of Residential Admission
Form is available at bluecrossmn.com. Blue Plus will notify you
that the information has been received.
Discharge Notification
Please notify Blue Plus of a discharge from extended care or
halfway house services by calling (651) 662-5270 or
1-800-528-0934; prompts will direct you to the correct option to
leave the discharge date. You may also fax discharge information
to (651) 662-0718. When reporting a discharge, please provide the
following information:
Member name and ID #
Blue Plus case number provided by Blue Plus
Provider name, contact name and contact phone number
Discharge date
Partial psych services must be billed as an outpatient service under
revenue codes 0912 or 0913. Detailed billing requirements are
listed below.
If your psychiatric unit is Medicare-certified, the following
instructions apply:
Bill using your NPI with the appropriate taxonomy code (partial
psych)
If the patient is not a Medicare member, submit claims using
TOB 013X (Hospital Outpatient) with revenue codes 0912-
0913 and HCPCS code H0035. For a child/adolescent program,
use H0035 with the HA modifier.
0912 – Behavioral health treatments/services – partial
hospitalization – less intensive
11-93

Coding Policies and Guidelines (Behavioral Health)
Partial Psychiatric
Billing (continued)
11-94
0913 – Behavioral health treatments/services – partial
hospitalization –intensive
H0035 – Mental health partial hospitalization, treatment,
less than 24 hours
HA – Child/adolescent program
If the patient is a Medicare member, submit claims using TOB
013X, condition code 41 and the Medicare-allowed revenue
codes:
0250 – Pharmacy (drugs and biologicals) (no HCPCS
required)
043X – Occupational therapy, partial hospitalization
(G0129)
0900 – Behavioral health treatments/services general
(90801, 90802 or 90899)
0904 – Activity therapy, partial hospitalization (G0176)
0914 – Individual psychotherapy (90816, 90817, 90818,
90819, 90821, 90822, 90823, 90824, 90826, 90827, 90828
or 90829)
0915 – Group therapy (90849, 90853 or 90857)
0916 – Family psychotherapy (90846, 90847 or 90849)
0918 – psychiatric testing (96101-96103, 96116, 96118-
96120)
0942 – Education training (G0177)
Partial Program is not Hospital-Based
If your partial program is not hospital-based but is part of a
community mental health center in accordance with
MS256B.0625, subd 5 and is certified by Medicare to provide
partial hospitalization, bill using your NPI with your partial psych
taxonomy code, using TOB 013X and revenue codes 0912-0913.
Hospital outpatient claims generally require submission of the
appropriate HCPCS code along with the revenue code. The
behavioral health (0900-0919) and the education training (0942)
revenue codes require submission of a HCPCS code.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12

Rule 5 - Emotionally
Handicapped Facilities
Children’s Residential
Mental Health
(Medicaid Government
Programs only)
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12
Coding Policies and Guidelines (Behavioral Health)
Rule 5 facilities must have state licensure to provide services.
Preadmission notification is recommended.
Services are processed under the patient’s residential benefits
and are subject to any day or dollar limitations. Some selfinsured
contracts may deny services as a contract exclusion.
Benefits may end the day the patient turns 18. Each contract
should be checked for clarification on this benefit.
The Minnesota Department of Human Services (DHS) has
determined that the managed care organizations shall be
responsible for the rehabilitative services and other medical costs
for Minnesota Health Care Programs members while the child
resides in the children’s residential mental health treatment facility
and remains in managed care. In order for Blue Cross to be in
compliance with this required benefit change, a contract
amendment has been issued to all Blue Cross participating
children’s residential mental health institutional providers who are
located in Minnesota and hold host county contracts.
Prior Authorization
Prior authorization from Blue Cross and the county will be
required for all children’s residential mental health treatment
facilities. To begin this process, please contact Behavioral Health
Service at 1-800-262-0820.
Coverage
Coverage is subject to the terms of the member’s benefit plan.
Provider is responsible to verify eligibility and coverage before
services are rendered.
Reimbursement
For the Minnesota Health Care Program members affected by this
benefit change, Blue Plus will reimburse the provider for the
rehabilitative services at 100 percent (100%) of the provider’s
charge. Per diem rates paid to the provider shall be the portion of
the per-day contract rate that relates to the rehabilitative mental
health services plus two percent (2%) and shall not include group
foster care costs or services that are billed to the county of
financial responsibility.
11-95

Coding Policies and Guidelines (Behavioral Health)
Children’s Residential
Mental Health
(Medicaid Government
Programs only)
(continued)
IRTS (Medicaid
Government Programs
Only)
11-96
Providers may bill Blue Plus the then-current county rate at the
percentage determined by DHS to be eligible for reimbursement
by Medical Assistance plus two percent (2%). Further, the
provider should seek reimbursement for the room and board
portion of facility costs from the local agency (County), not from
Blue Plus.
Groups Affected
This change applies to the following Minnesota Health Care
Programs:
Blue Plus
Product Name Group Numbers
Blue Advantage (PMAP) PP021, PP022, PP024, PP025,
PP026, PP027
MinnesotaCare PP111, PP112, PP151, PP152
Blue Cross will reimburse certain categories of providers for these
services, which were formerly reimbursed through the Minnesota
Department of Human Services (DHS).
This change was effective for all enrollees in the Prepaid Medical
Assistance Programs (PMAP), Minnesota Senior Health Options
(MSHO) and Minnesota Disabled Health Options (MnDHO).
Crisis response services include:
Crisis assessment
Crisis intervention
Crisis stabilization
Community intervention
The following summarizes provider eligibility, member eligibility
and operational requirements for Blue Plus providers of these
services.
All members of the following Blue Plus products are eligible to
receive these services:
Blue Advantage (Blue Plus PMAP, and Minnesota Senior
CarePlus)
MinnesotaCare
CareBlue
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12

IRTS (Medicaid
Government Programs
Only) (continued)
IRTS/Crisis Provider
Eligibility
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12
Coding Policies and Guidelines (Behavioral Health)
Group numbers for these products are listed below.
Blue Plus
Products Group Numbers
Blue
Advantage
Minnesota
Senior Care
Plus
MinnesotaCare
Expanded
MinnesotaCare
Basic Plus,
Basic +1,
Basic +2
SecureBlue
(MSHO)
PP011, PP012, PP014, PP015, PP016, PP017,
PP021, PP022, PP024, PP025, PP026, PP027,
PP031, PP032, PP034, PP035, PP036, PP037,
PP411, PP412, PP414
PP041, PP042, PP044, PP051, PP052, PP054,
PP055, PP056, PP057, PP061, PP062, PP064,
PP071, PP072, PP074, PP075, PP076, PP077
PP111, PP112, PP151, PP152
PP121, PP122, PP131, PP132, PP141, PP142,
PP161, PP162, PP163, PP164
PP200, PP201, PP202, PP215, PP220, PP221,
PP222, PP240, PP245, PP260, PP261, PP262,
PP280, PP281, PP282
Members with commercial coverage may be eligible to receive
these services. Please verify member eligibility using one of the
resources described below under Member eligibility.
To provide this type of treatment, providers must:
Be licensed under Rule 36
Have DHS approval
Be a participating provider with Blue Cross
Professional treatment services may only be provided by an
eligible IRTS Crisis provider.
11-97

Coding Policies and Guidelines (Behavioral Health)
IRTS Member
Eligibility
IRTS Access to
Services
Billing for IRTS or
Residential Crisis
Court Ordered
Treatment
11-98
Providers are expected to check the member’s eligibility before
rendering services. Resources available for verification include:
MN-ITS
www.mn-its.dhs.state.mn.us
EVS
1-800-657-3613
Provider Web Self-Service
www.providerhub.com
Provider Services
1-800-262-0820
Direct access to contracted providers
No prior authorizations required
No referrals required
Non-contracted providers must obtain a referral from provider
services at 1-800-262-0820 prior to delivering treatment.
When reporting room and board and/or treatment services, report
on the 837I type of bill 86X, with the room and board and
treatment services as separate line items. Submit the room and
board charges under revenue code 1001 and the treatment services
under revenue codes 090X or 091X.
When room and board and treatment are billed to separate entities,
treatment is reported on the 837P, with HCPCS code H0018 or
H0019.
When a court order for treatment is based on an evaluation and
recommendation by a physician, licensed Ph.D. level psychologist,
licensed alcohol and drug dependency counselor or a certified
chemical dependency assessor (rule 25) we will consider the order
for treatment medically necessary.
Blue Cross will provide coverage for these court ordered services
according to the patient's contract benefits. For example, if the
member does not have inpatient chemical dependency benefits and
the patient is court ordered into inpatient chemical dependency
treatment, there will be no coverage for the services.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12

Court Ordered
Treatment
(continued)
Preadmission
Notification
Residential Substance
Abuse Admission and
Concurrent Review
Process Change
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12
Coding Policies and Guidelines (Behavioral Health)
If a participating provider is providing services, a copy of the court
order should be retained in the patient’s chart in the provider’s
office. If the patient sees a nonparticipating provider, a copy of the
court order and MN Universal form should be submitted as soon as
possible so the necessary approval can be entered into the claim
system to ensure accurate payment of any claims. This can be
faxed to Integrated Health Management at (651) 662-0854.
If the court order is to a specific non-network provider but the
member does not have any benefits for non-network providers,
Blue Cross will cover the services as they would for in-network
providers. However, fee-for-service members will be responsible
for the difference between the billed amount and Blue Cross'
allowed amount.
Call (651) 662-2474 or 1-800-262-0820 or fax form X13459 to
(651) 662-0856 to notify Blue Cross of admissions into day
treatment, partial psychiatric or inpatient programs.
PAN Requirements
A PAN is required for all residential substance abuse services,
including services that were previously determined to be halfway
house or extended care. Coverage for services is based on the
specifics of each member’s benefits. The PAN requirement is for
all members who are enrolled in a fully insured plan or Minnesota
Health Care Program.
Concurrent Review
In addition to the PAN requirements, at day 21 of an
inpatient/residential stay, a concurrent review is required with a
medical necessity review. Blue Cross will conduct the medical
necessity review based on an updated completion of the
Department of Human Services (DHS) Dimensions Criteria and
the submission of a current individualized treatment plan. A copy
of the DHS Dimensions Criteria and Assessment is located on the
DHS website at
http://edocs.dhs.state.mn.us/lfserver/Legacy/DHS-2794-ENG.
Blue Cross will not provide courtesy calls to providers notifying
them of missing preadmission notification (PAN) or concurrent
review information. If PAN or concurrent review information is
not received, the claim will deny as provider liability.
11-99

Coding Policies and Guidelines (Behavioral Health)
Residential Substance
Abuse Admission and
Concurrent Review
Process Change
(continued)
Pre-certification and
Concurrent Review for
Inpatient/Residential
Mental Health and
Substance Use
Disorder services
11-100
PAN Form
If you have provider web self-service, submit the PAN request
electronically by creating an admission notification on
providerhub.com. A copy of the PAN form is also available on
the Blue Cross website at providers bluecrossmn.com. For
providers that do not have provider web self-service, the PAN
form should be faxed to (651) 662-7006 or called in to
(651) 662-5200 or 1-800-262-0820.
Blue Cross Policy
Failure to comply with the PAN or concurrent review requirements
within 10 business days from the request will result in claims
being denied as provider liability.
To help assure that members receive the appropriate level of care
for mental health and substance use disorder treatment, Blue
Cross, as done with other medical/surgical services, implemented
certain pre-certification and concurrent review protocols for
inpatient/residential services.
This program will continue to expand throughout 2010, and
impacted providers will receive additional information once these
requirements are expanded.
Pre-certification and concurrent review applies to health services
provided to members in fully insured and self-insured benefit
plans, including Minnesota Health Care Programs, with the
exception of Minnesota Senior Care Plus (MSC+), SecureBlue
(HMO SNP), (HMO), Platinum Blue (Cost) and MedicareBlue
PPO (Regional PPO) members. Medicare supplement benefit plans
are also excluded from review. This also does not apply to court
ordered admissions to inpatient/residential treatment. Coverage for
court ordered mental health services is detailed in Minnesota
Statute 62Q.535.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12

Pre-certification and
Concurrent Review for
Inpatient/Residential
Mental Health and
Substance Use
Disorder services
(continued)
Definitions
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12
Coding Policies and Guidelines (Behavioral Health)
"Pre-certification" means an advance review of a proposed facility
admission or certain services or procedures in order to determine
whether the proposed admission, services or procedures meet the
medical necessity criteria for payment and to ensure that the
subscriber receives the maximum benefits available under the
subscriber’s plan. "Concurrent review" means ongoing review
during the subscriber’s care, to ensure that it meets established
medical criteria in a timely manner and certifies the necessity, and
the appropriateness, and quality of services during an inpatient
admission.
Pre-certification Requirements
Provider will obtain pre-certification from Blue Cross before
admitting a member. If admission is emergent or after business
hours, provider will obtain pre-certification within two (2)
business days after the admission.
Provider shall obtain pre-certification by calling Blue Cross at
(651) 662-5270 or toll free at 1-800-528-0934. Blue Cross will use
criteria set forth in the Level of Care Utilization System (LOCUS)
and Child and Adolescent Services Intensity Instrument (CASII)
for mental health or the Dimensions criteria for substance use
disorders in conducting a medical necessity review for the
admission.
Failure to provide evidence of medical necessity may result in
claim denials as provider liability.
Concurrent Review Requirements
Providers have a contractual obligation as noted in Chapter 4 of
the online Blue Cross Provider Policy and Procedure Manual to
adhere to care management programs. At the time of precertification
a date will be established to conduct concurrent
review.
Concurrent review will include verification of medical necessity
based on criteria set forth in the LOCUS and CASII for mental
health or the Dimensions criteria for substance use disorders.
Failure to provide evidence of medical necessity may result in
claim denials as provider liability.
11-101

Coding Policies and Guidelines (Behavioral Health)
Referrals Blue Cross does not require a referral for patients seeking care
within the Select Behavioral Health Network. For complete
information on requirements for Minnesota Health Care Programs,
see Chapter 3 of the Blue Plus Manual.
11-102
Services sought outside the Select Behavioral Health Network but
within the Aware network will be processed according to the
patient's self-referral benefit. If the patient has specialty needs,
continuity of care issues, transition of care issues, or cannot access
behavioral health services within the required provider network
within a reasonable time period or due to geographical or physical
accessibility reasons, the provider should contact Blue Cross and
request a referral. A referral may be approved depending on the
patient's situation.
If services are sought outside both the Select network and the
Aware network and the member does not have self-referral
benefits, then Blue Cross should be contacted and the situation
reviewed for a possible referral approval.
Parity Federal and state mandates dictate mental health parity laws that
are applicable to all fully insured groups. Self-insured groups are
not subject to parity legislation, but they may elect to follow these
laws.
Parity means that treatment for substance abuse and/or mental
health is covered the same as any other inpatient and/or outpatient
medical benefit. For example, if a member has coverage for an
illness E/M service from a non-network provider, then that
member will also have coverage for a behavioral health service
from a non-network provider.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12

Groups that Carve Out
Behavioral Health
Benefits
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12
Coding Policies and Guidelines (Behavioral Health)
Some self-insured groups contract with another carrier to manage
their behavioral health benefits. This means that their behavioral
health claims should be filed to the designated third party
behavioral health carrier for processing. This carrier’s information
should be obtained from the patient.
E/M services (codes 99201-99215) and medication management
services (codes 90862 or M0064) billed with a behavioral health
diagnosis for carve out group members should be billed to Blue
Cross as long as the practitioner is a non-behavioral health
practitioner or a multi-specialty clinic. If one of these services is
denied, Blue Cross should be contacted for it to be reprocessed.
These services will be paid at the behavioral health benefit but will
not accumulate towards patients’ behavioral health benefit
maximums. Any other behavioral health treatment for carve out
group members that is billed to Blue Cross will be denied.
Provider Networks There are two behavioral health provider networks: the Select
Behavioral Health Network and the Aware network.
Most Blue Plus patients are required to utilize a Select provider for
their highest level of benefits. Many but not all members have selfreferral
benefits that are applied when services are obtained in the
Aware network. To find a participating Select network provider,
members are encouraged to call Blue Cross so that a provider best
suited to meet their treatment needs can be found in a convenient
location.
The majority of fee-for-service members have direct access to an
Aware network practitioner.
Fully insured groups have the Select Behavioral Health Network.
Some self-insured groups have the Select Behavioral Health
Network while other self-insured groups may choose the Aware
Network. Individual Accounts use the Aware Network.
11-103

Coding Policies and Guidelines (Behavioral Health)
Institutional Behavioral Health Coding Information
Blue Cross and Blue Shield of Minnesota and Blue Plus
Code Description Units Notes on
Use/Coverage
0900 Behavioral Health Treatments/Services,
General Classification
0901 Behavioral Health Treatments/Services,
Electroshock Treatment
0902 Behavioral Health Treatments/Services,
Milieu Therapy
0903 Behavioral Health Treatments/Services,
Play Therapy
0904 Behavioral Health Treatments/Services,
Activity Therapy
0905 Behavioral Health Treatments/Services,
Intensive Outpatient Services – Psychiatric
0906 Behavioral Health Treatments/Services,
Intensive Outpatient Services – Chemical
Dependency
0907 Behavioral Health Treatments/Services,
Community Behavioral Health Program
(Day Treatment)
0911 Behavioral Health Treatments/Services,
Rehabilitation
0912 Behavioral Health Treatments/Services,
Partial Hospitalization - Less Intensive
11-104
1 unit based on
CPT/HCPCS
1 unit based on
CPT/HCPCS
1 unit based on
CPT/HCPCS
1 unit based on
CPT/HCPCS
1 unit based on
CPT/HCPCS
1 unit based on
CPT/HCPCS
1 unit based on
CPT/HCPCS
1 unit based on
CPT/HCPCS
1 unit based on
CPT/HCPCS
1 unit based on
CPT/HCPCS
Compatible with
behavioral health and
accident dx only
Compatible with
behavioral health and
accident dx only
Not covered
Compatible with
behavioral health and
accident dx only
Not covered
Compatible with
behavioral health
and accident dx
only
Only use for
psychiatric
rehabilitation
Compatible with
behavioral health and
accident dx only
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12

Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12
Coding Policies and Guidelines (Behavioral Health)
Code Description Units Notes on
Use/Coverage
0913 Behavioral Health Treatments/Services,
Partial Hospitalization - Intensive
0914 Behavioral Health Treatments/Services,
Individual Therapy
0915 Behavioral Health Treatments/Services,
Group Therapy
0916 Behavioral Health Treatments/Services,
Family Therapy
0917 Behavioral Health Treatments/Services,
Bio Feedback
0918 Behavioral Health Treatments/Services,
Testing
0919 Behavioral Health Treatments/Services,
Other Behavioral Health
Treatments/Services
1 unit based on
CPT/HCPCS
1 unit based on
CPT/HCPCS
1 unit based on
CPT/HCPCS
1 unit based on
CPT/HCPCS
1 unit based on
CPT/HCPCS
1 unit based on
CPT/HCPCS
1 unit based on
CPT/HCPCS
0944 Drug Rehabilitation 1 unit based on
CPT/HCPCS
0945 Alcohol Rehabilitation 1 unit based on
CPT/HCPCS
0949 Other Therapeutic Services 1 unit based on
CPT/HCPCS
1000 Behavioral Health Accommodations,
General Classification
1001 Behavioral Health Accommodations,
Residential Treatment – Psychiatric
1002 Behavioral Health Accommodations,
Residential Treatment – Chemical
Dependency
Compatible with
behavioral health and
accident dx only
Compatible with
behavioral health and
accident dx only
Compatible with
behavioral health and
accident dx only
Compatible with
behavioral health and
accident dx only
Incompatible with
routine, prenatal or
maternity dx
Incompatible with
routine, prenatal or
maternity dx
Compatible with
behavioral health and
accident dx only
Compatible with
behavioral health and
accident dx only
Compatible with
behavioral health and
accident dx only
Requires description of
service
1 per day Room and board
1 per day Room and board
1 per day Room and board
11-105

Coding Policies and Guidelines (Behavioral Health)
Code Description Units Notes on
Use/Coverage
1003 Behavioral Health Accommodations,
Supervised Living
1004 Behavioral Health Accommodations,
Halfway House
1005 Behavioral Health Accommodations,
Group Home
11-106
1 per day Room and board
Not covered
1 per day Room and board
Not covered
1 per day Room and board
Not covered
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12

Chapter 11
Coding Policies and Guidelines
(Chiropractic)
Table of Contents
Coding Overview................................................................................................................. 11-2
Examination Codes ..............................................................................................................11-2
Chiropractic Manipulation Treatment.................................................................................. 11-3
Chiropractic Manipulation with Visit .................................................................................. 11-4
Manual Therapy................................................................................................................... 11-4
Massage Therapy ................................................................................................................. 11-5
Conjunctive Therapy, Modality: Office, Home or Nursing Home......................................11-6
Maintenance or Palliative Care............................................................................................ 11-6
Source of Condition ............................................................................................................. 11-6
Diagnostic Services.............................................................................................................. 11-6
Radiology Coverage Restriction.......................................................................................... 11-7
Practicing in Multidisciplinary Clinics ................................................................................11-7
Documentation Guides......................................................................................................... 11-8
Prior Authorization .............................................................................................................. 11-9
Form Required ..................................................................................................................... 11-9
MHCP Chiropractic Authorization Process....................................................................... 11-10
Compliance Audits............................................................................................................. 11-12
Blue Cross Blue Shield of Minnesota Provider Policy and Procedure Manual (03/06/12) 11-1

Coding Policies and Guidelines (Chiropractic)
Coding Overview Chiropractors should use CPT codes when billing for services.
Providers should submit the code that most accurately identifies
the service(s) performed, paying close attention to the attended
versus unattended procedures (for example, 97032 versus 97014).
The fact that a code exists does not guarantee the service is
covered for all Blue Cross and Blue Shield of Minnesota members.
The member's health coverage contract defines the services that
are eligible for payment.
Examination Codes An examination includes inspection of the patient and review of
diagnostic tests to diagnose disease or evaluate progress. Use of
the E/M codes must be supported within your medical record.
11-2
Per CPT, "Chiropractic manipulative treatment codes (98940-
98943) include a pre-manipulation patient assessment. Additional
E/M services may be reported separately using the modifier -25, if
the patient's condition requires a significant, separately identifiable
E/M service, above and beyond the usual pre-service and postservice
work associated with the procedure."
It would be inappropriate to bill 99214, 99215, 99204 or 99205
along with manipulative treatment codes. These will be rejected as
provider liability. Because a level 4 or 5 would require significant
additional work, it would seldom be appropriate to bill both.
Documentation in the patient’s record must support the additional
E/M service.
As noted by the Minnesota Chiropractic Association, an E/M
would be appropriate for the following situations:
New Patient
A new patient is one who has not received any professional
services from the chiropractor or another chiropractor in the same
group practice within the past three years.
Established Patient – New Injury or Exacerbation
The E/M is needed to obtain history and fully evaluate the patient's
condition for an initial treatment plan or, in the event of an
exacerbation, modify a previous treatment plan.
Blue Cross Blue Shield of Minnesota Provider Policy and Procedure Manual (03/06/12)

Examination Codes
(continued)
Chiropractic
Manipulation
Treatment
Established Patient – Re-examination
Coding Policies and Guidelines (Chiropractic)
Periodic examinations are typically performed in order to formally
assess the patient's response to treatment, progress, and make
necessary changes to the treatment plan.
For any of the above circumstances, a -25 modifier must be
submitted on the E/M service if there was a significant separately
identifiable E/M service.
The chiropractic manipulation treatment codes (CMT) include a
pre-manipulation patient assessment, the adjustment, and
evaluation of the effect of treatment. The CMT codes 98940-98942
are used to indicate the number of spinal areas manipulated. CMT
code 98943 is used to report chiropractic manipulation of one or
more of the extra-spinal regions (head region; lower extremities;
upper extremities; rib cage; abdomen).
PRE Service
PRE Service work may include a review of:
•
•
•
•
•
•
•
•
•
•
•
•
the patient’s records
their diagnostic tests
communication with other providers
the actual preparations for care
INTRA Service
INTRA Service work would include:
discussion about the service with the patient
a pertinent evaluation and assessment of the patient
the procedure
POST Service
POST Service work includes:
an evaluation and discussion with the patient about the effect
of treatment
arrangement of additional services or referral to another
provider
discussion of the case with other providers
review of literature about the patient’s condition
documenting the service
Blue Cross Blue Shield of Minnesota Provider Policy and Procedure Manual (03/06/12)
11-3

Coding Policies and Guidelines (Chiropractic)
Chiropractic
Manipulation with Visit
If an evaluation and management service is done with the
manipulation, the E/M will deny unless it is submitted with a -25
modifier, signifying significant, separately identifiable illness or
injury. A level 4 or 5 E/M (99204, 99205, 99214, 99215) will be
denied as provider liability because these levels would require
significant additional work, and it is seldom appropriate to bill
both.
Manual Therapy 97140, manual therapy techniques (e.g., mobilization/
manipulation, manual lymphatic drainage, manual traction), one or
more regions, each 15 minutes.
11-4
Blue Cross and Blue Shield of Minnesota and Blue Plus will not
reimburse providers for manual therapy services. Manual therapy
will deny either as incidental (provider liability) or subscriber
liability.
Provider liable:
Manual therapy (97140) will be denied incidental (provider liable)
to chiropractic manipulations billed on the same date of service.
The denial will be upheld regardless of submission of the -59
modifier. Based on chart documentation review, Blue Cross found
that manual therapy services submitted with the -59 modifier did
not clearly indicate it as a distinct service. Thus we have adopted a
corporate policy to disallow 97140 submitted with the -59
modifier. Additionally, submission of the -GA modifier will not
affect or change the denial.
Patient Billing Impact
The patient is not responsible and must not be balance billed for
any procedures for which payment has been denied or reduced by
Blue Cross as the result of a coding edit. Edit denials are designed
to ensure appropriate coding and to assist in processing claims
accurately and consistently.
Subscriber liable:
Coverage for manual therapy (97140) services provided without a
chiropractic manipulation is subject to the members’ contract
benefits.
Blue Cross Blue Shield of Minnesota Provider Policy and Procedure Manual (03/06/12)

Coding Policies and Guidelines (Chiropractic)
Massage Therapy 97124 Therapeutic procedure, one or more areas, each 15 minutes;
massage, including effleurage, petrissage and/or tapotement
(stroking, compression, percussion).
Blue Cross and Blue Shield of Minnesota and Blue Plus will not
reimburse providers for massage therapy services. Massage
therapy will deny either as incidental (provider liability) or
subscriber liability.
Massages that are provided as preparation for a chiropractic
manipulation are considered an integral part of the chiropractic
manipulation. As such, we will deny it as provider liability. If a
massage is billed alone, then it will be denied as a subscriber
contract exclusion.
Provider liable:
Massage therapy (97124) will be denied incidental (provider
liable) to chiropractic manipulations billed on the same date of
service. The denial will be upheld regardless of submission of the -
59 modifier. Based on chart documentation review, Blue Cross
found that massage therapy services submitted with the -59
modifier did not clearly indicate it as a distinct service. Thus we
have adopted a corporate policy to disallow 97124 submitted with
the -59 modifier. Additionally, submission of the -GA modifier
will not affect or change the denial.
Patient Billing Impact
The patient is not responsible and must not be balance billed for
any procedures for which payment has been denied or reduced by
Blue Cross as the result of a coding edit. Edit denials are designed
to ensure appropriate coding and to assist in processing claims
accurately and consistently.
Subscriber liable:
Coverage for massage therapy (97124) services provided without a
chiropractic manipulation is subject to the member’s contract
benefits. Many benefit plans do not cover this service.
An independent massage therapist is an ineligible provider.
When a massage therapist is employed and supervised by the
chiropractor, chiropractor should submit procedure code 97124
with a -U7 modifier.
Blue Cross Blue Shield of Minnesota Provider Policy and Procedure Manual (03/06/12)
11-5

Coding Policies and Guidelines (Chiropractic)
Conjunctive Therapy,
Modality: Office, Home
or Nursing Home
Maintenance or
Palliative Care
Therapies must be used in conjunction with adjustment or
manipulation on the same day for most contracts. If more than one
therapy is done per treatment, submit documentation with the
claim to support the necessity for the additional therapy.
Rehabilitation services that would not result in measurable
progress relative to established goals are non-covered services.
The “AT” modifier distinguishes active/corrective treatment from
maintenance therapy. The AT modifier should be appended to the
chiropractic manipulation (98940-98943). The absence of the AT
modifier would indicate maintenance or palliative care.
Source of Condition Incorrect coding of "source of condition" is the major reason for
delay in processing chiropractic claims. Follow the procedures
outlined below to eliminate claim delays.
Illness
Typically an illness diagnosis is found in the 700 range of
ICD-9-CM codes. If services are not related to a specific injury,
choose a diagnosis code outside of the ranges given below.
Injury
Injury is defined as bodily harm caused by an accident. The term
includes all related conditions and recurrent symptoms. If services
are related to a specific injury, choose a diagnosis code in the
800-977 and 980-994 ranges.
Submit the date of injury whenever the services are related to a
specific injury. An exacerbation is not necessarily the result of an
injury; therefore the appropriate illness diagnosis should be
submitted.
Diagnostic Services Use CPT codes to submit laboratory and X-ray services. The
number of services on your claim must be the number of
procedures performed not the number of views taken.
11-6
For example:
Code Units
71020 (Chest X-ray, 2 views) 1
Blue Cross Blue Shield of Minnesota Provider Policy and Procedure Manual (03/06/12)

Radiology Coverage
Restriction
Practicing in
Multidisciplinary
Clinics
Coding Policies and Guidelines (Chiropractic)
Blue Cross will not reimburse for many imaging services when
billed by a chiropractor. This policy applies to all High Tech
Diagnostic Imaging (HTDI) procedures, including CT Scans and
MRI services, in addition to the procedures below. This will allow
Blue Cross to better manage these high-cost radiology services.
These claims will be denied as provider liability.
71260 71550 72192 72193 72194
73221 73721 74150 74160 74170
74183 76140 76496 76536 76800
76856 76870 76977 77057 77080
Blue Cross will continue to allow chiropractors to order medically
necessary radiology services, as permitted by the provider’s scope
of practice. In instances where HTDI is ordered, chiropractors
should direct patients to designated HTDI providers. For additional
information on HTDI requirements, and a list of HTDI providers
and procedures, reference the Blue Cross website at
providers.bluecrossmn.com and select High Tech Diagnostic
Imaging under Tools & Resources.
Services billed for consultation on X-ray exams performed
elsewhere (CPT 76140) will not be payable, as Blue Cross already
reimburses for both the professional and technical component of
most radiology services. Re-interpretation of a film is a duplication
of these other components.
Blue Cross will continue to allow chiropractors to perform, bill
and be reimbursed for most traditional X-ray films based on the
member’s benefits.
Chiropractors practicing in multidisciplinary clinics shall maintain
a separate contract and billing number.
Blue Cross Blue Shield of Minnesota Provider Policy and Procedure Manual (03/06/12)
11-7

Coding Policies and Guidelines (Chiropractic)
Documentation Guides To avoid denials for medical necessity, the patient’s medical
record must contain certain pertinent information that may be
subject to our review. The Centers for Medicare and Medicaid
Services (CMS) in conjunction with the American Medical
Association (AMA) has developed guidelines for the medical
documentation necessary to support a given level of evaluation and
management service. Blue Cross has adopted these guidelines to
ensure that our members receive quality care and that the services
are consistent with the insurance coverage provided. The general
guidelines are listed below:
11-8
•
•
•
•
•
•
•
The medical record should be complete and legible.
The documentation of each patient encounter should include:
• reason for the encounter and relevant history, physical
examination findings and prior diagnostic test results
• plan of care
Documentation must be signed and dated by the practitioner
rendering the service; electronic signature is acceptable but
must be noted on the record.
If not documented, the rationale for ordering diagnostic and
other ancillary services should be easily inferred.
Past and present diagnoses should be accessible to the treating
and/or consulting physician.
Appropriate health risk factors should be identified.
The patient’s progress, response and changes in treatment, and
revision of diagnosis should be documented.
Blue Cross Blue Shield of Minnesota Provider Policy and Procedure Manual (03/06/12)

Documentation Guides
(continued)
•
•
Coding Policies and Guidelines (Chiropractic)
The CPT/HCPCS and ICD-9-CM codes reported on the health
insurance claim form or billing statement should be supported
by the documentation in the medical record. Charge slips,
super bills, travel cards, or office ledgers are not considered
supporting documentation for services provided to a patient.
Use of the term IBID and/or the use of quotation marks to
replace or repeat previously documented information is not
acceptable. All information must be in date-sequence order.
Services not documented as indicated are not covered by Blue
Cross. Patients are not financially liable for services that are
denied for inadequate documentation. In addition, chart
documentation should clearly list the name of the practitioner
rendering services to the member, including the names and
credentials of employees providing care under the supervision of a
chiropractor.
Prior Authorization Chiropractic services rendered by Aware Chiropractic Providers
are not subject to prior authorization for members of Blue Cross
and Blue Shield of Minnesota fully insured groups. For Blue Cross
self-insured groups, it is recommended that prior authorization for
chiropractic services will be done after 20 visits. Benefits are
allowable only for services that are medically necessary. Providers
are encouraged to use provider web self-service or BLUELINE to
obtain member benefits prior to beginning services.
Form Required To obtain prior authorization, providers should complete the
Chiropractic Medical Information Request Form, form number
F4355 R12. This form can be found on the Blue Cross web site.
Blue Cross Blue Shield of Minnesota Provider Policy and Procedure Manual (03/06/12)
11-9

Coding Policies and Guidelines (Chiropractic)
MHCP Chiropractic
Authorization Process
11-10
Blue Plus requires prior authorization for chiropractic services
beyond 12 visits per calendar year for Minnesota Health Care
Programs members. Commercial lines of business are not
impacted by this change.
Minnesota Health Care Programs
Group numbers for the affected products are as follows:
Product Name Group Numbers
Blue Advantage
(PMAP)
PP011, PP012, PP014, PP015, PP016,
PP017, PP021, PP022, PP024, PP025,
PP026, PP027, PP031, PP032, PP034,
PP035, PP036, PP037
MinnesotaCare PP111, PP112, PP151, PP152, PP121,
PP122, PP131, PP132, PP141, PP142,
PP161, PP162, PP163, PP164
Minnesota Senior Care
Plus (MSC+)
SecureBlue SM (HMO
SNP)
PP041, PP042, PP044, PP051, PP052,
PP054, PP055, PP056, PP057, PP061,
PP062, PP064, PP071, PP072, PP074,
PP075, PP076, PP077
All group numbers that begin with PP2
Blue Cross Blue Shield of Minnesota Provider Policy and Procedure Manual (03/06/12)

MHCP Chiropractic
Authorization Process
(continued)
Documentation Required
Coding Policies and Guidelines (Chiropractic)
Prior authorization for visits beyond 12 should be submitted two
weeks in advance of reaching the 12th visit. Fax your Blue Plus
member requests to: (651) 662-4022 or 1-866-800-1665.
Documentation needs to include all of the following information:
•
•
•
•
Evaluation and diagnosis: Indicate how the subluxation
diagnosis was determined
Chief complaint: List member’s symptoms
Assessment and treatment plan: Provide your physical
assessment and treatment plan including when the member will
be discharged, number of visits planned and frequency planned
Rationale for continued treatment: Provide evidence of
member’s improvement with chiropractic services
Prior Authorization Process
To initiate prior authorization complete the Chiropractic Medical
Information Request Form found in the forms section of
providers.bluecrossmn.com. You may also submit supporting
information from your chart records in addition to completing the
form. All documentation needs to be legible.
The timeline for decisions is up to 10 business days. Decisions will
be communicated via telephone or fax, and letter. Approvals are
communicated via telephone with a letter as follow up. Denials are
communicated with a fax copy of the denial letter and a follow-up
letter sent by mail.
MHCP coverage guidelines are followed for Minnesota Health
Care Program members. All services must be medically necessary
for continued coverage.
Blue Cross Blue Shield of Minnesota Provider Policy and Procedure Manual (03/06/12)
11-11

Coding Policies and Guidelines (Chiropractic)
Compliance Audits Your provider service agreement includes certain quality assurance
requirements. Pursuant to this agreement, Blue Cross may conduct
audits to evaluate a provider’s compliance with medical necessity
guidelines and standards of practice in the community. Such an
audit could include post-service claims review using provider
utilization thresholds established by Blue Cross which may result
in provider liability if care is determined to be not medically
necessary or medically inappropriate.
11-12
Medical necessary services are directed toward a diagnosis or
condition that is supported by documented subjective and objective
findings. Medically necessary care means health care services are
appropriate, in terms of type, frequency level, setting and duration,
to the member’s diagnosis or condition, and diagnostic testing and
preventive services (Minnesota Rules 4685.0100 Subp.5). The
intensity of treatment must be consistent with the severity or acuity
of the patient’s current level of impairment and/or
symptomatology. Additionally, there must be documentation of
reasonable progress consistent with the intensity of treatment and
the severity/acuity of the patient’s condition.
Blue Cross Blue Shield of Minnesota Provider Policy and Procedure Manual (03/06/12)

Chapter 11
Coding Policies and Guidelines
(Dental Services)
Table of Contents
Medical-Surgical Procedures............................................................................................... 11-2
Prior Authorization .............................................................................................................. 11-3
Claim Form ..........................................................................................................................11-3
Coordination Between Dental and Medical Carriers........................................................... 11-4
TMJ Claims Submission......................................................................................................11-4
Diagnostic Studies ............................................................................................................... 11-5
Emergency Room.................................................................................................................11-5
Dental Aware .......................................................................................................................11-5
Dental Procedures and Pre-op/Medical Exams.................................................................... 11-5
Blue Cross Blue Shield of Minnesota Provider Policy and Procedure Manual (03/06/12) 11-1

Coding Policies and Guidelines (Dental Services)
Medical-Surgical
Procedures
11-2
Many of our member contracts cover several medical-surgical
procedures that dentists perform. The procedures are:
• Treatment (repair or replacement only) of accidental injury to
natural teeth, which is not regular dental repair or maintenance.
• Surgical and nonsurgical treatment of TMJ and
craniomandibular disorder.
• Treatment of cleft lip and palate for a dependent child up to
age 19, if medically necessary.
• Reconstructive surgery to correct a functional physical defect
for dependent children — this would include orthognathic
surgery. Treatment involving dental implants is specifically
excluded.
• Removal of cysts/lesion(s)/tumor(s) and the accompanying
pathology reports, scans, and anesthesia and allowable
supplies.
Certain dental services may be reported using either a CPT or
dental HCPCS code. CPT codes are generally five numeric digits.
Dental HCPCS codes, which are developed by the American
Dental Association (ADA), start with the letter D and are followed
by four numeric digits.
It is important to note that pricing will vary between a comparable
CPT and dental HCPCS code and that claims will be reimbursed
based on the pricing associated with the code submitted. Pricing
for CPT codes is based on Resource Based Relative Value System
(RBRVS). Pricing for dental HCPCS codes is based on Delta
Dental pricing.
Blue Cross Blue Shield of Minnesota Provider Policy and Procedure Manual (03/06/12)

Coding Policies and Guidelines (Dental Services)
Prior Authorization If a service requires prior authorization, make sure the CPT or
dental HCPCS procedure code on the claim is the same as on the
prior authorization. For example, if a dental HCPCS code is
approved on a prior authorization, use the same code on the claim.
Prior authorization requests
Begin mailing or faxing prior authorization (PA) requests to:
Utilization Management Dept. R4-72
Blue Cross and Blue Shield of Minnesota
P.O. Box 64265
St. Paul, MN 55164-0265
Fax: (651) 662-7816
Prior authorization recommendations
PAs are recommended for the following services:
•
•
•
•
•
Surgical TMJ services
Orthognathic/osteotomies
Orthodontics for TMJ and cleft lip/palate
Bone grafts
Treatment related to accidental injuries
Claim Form Use an 837P electronic claim format when submitting dentalrelated
claims (the ADA claim form is accepted, but Blue Cross
prefers the 837P). If you are using the ADA form, be sure to
include the diagnosis if the treatment is accident related, for cleft
lip/palate or TMJ diagnosis or include the narrative.
Treatment of accidental injury to natural teeth
• Initial treatment must begin within 12 months of the accidental
injury and completed at 24 months from the date of initial
treatment.
• “Injury” does not include bruxism or biting and chewing.
• Complete the “date of injury” field on the claim. Submit the
appropriate accidental injury diagnosis code on the initial and
subsequent claims throughout treatment.
• Include documentation in support of the accidental injury
diagnosis or narrative description of the accident with the
claim.
Note: Prior authorization for anesthesia for children is not
required. Benefits are paid in accordance with the contract.
Blue Cross Blue Shield of Minnesota Provider Policy and Procedure Manual (03/06/12)
11-3

Coding Policies and Guidelines (Dental Services)
Coordination Between
Dental and Medical
Carriers
If you perform the types of service listed above for your patients,
bill Blue Cross as usual. If the patient has a dental plan in addition
to a medical-surgical policy, the dental plan is the primary payer.
Note: If you receive payments from both the dental and medical
plans for the same services, refund the medical carrier. We
will coordinate up to our U&C allowances or billed charges,
whichever is less.
TMJ Claims Submission The following guidelines should be used when preparing TMJrelated
disorder claims for submission:
11-4
Codes Guidelines
ICM-9-CM The primary diagnosis code should be 524.60-
524.69, temporomandibular joint disorders. All
other primary diagnosis codes submitted for TMJ
and craniomandibular disorders will be rejected.
HCPCS
codes
CPT codes
nonsurgical
CPT codes
surgical
The HCPCS code for orthotic therapy should be
D7880. All other orthotic codes submitted for TMJ
and craniomandibular disorders will be rejected.
Study casts and/or mounted or unmounted study
models are considered an integral part of the splint
therapy and should not be billed separately.
Orthotic adjustments and office call visits are
considered an integral part of the orthotic therapy
and should not be billed separately. Only the initial
visit may be billed separately.
The following procedure codes are considered
eligible for reimbursement for surgical services of
the temporomandibular joint: 21050, 21060, 21070,
21073, 21240, 21242, 21243, 29804 (TMJ
arthroscopy—surgical only).
Note: All postoperative office visits are considered
an integral part of the surgical fee and will be
denied if billed separately during the global
surgical period.
Blue Cross Blue Shield of Minnesota Provider Policy and Procedure Manual (03/06/12)

Coding Policies and Guidelines (Dental Services)
Diagnostic Studies The following radiographs are considered eligible for TMJ
disorders when medically necessary.
Procedure Codes
70328 70332 70355 70487
70330 70336 70486 70488
Benefits are not provided for cephalometric radiographs for TMJ
disorders.
Electromyography (EMG), Computerized Mandibular Scanner,
Computerized Jaw Tracking/Motion Analysis, Doppler
Auscultation, and Sonography/ultrasound are considered
investigative and therefore ineligible when used in the diagnosis
and treatment of temporomandibular and craniomandibular
disorders.
Emergency Room Emergency room services submitted with dental diagnosis will be
processed as a medical service.
Dental Aware All dental contracts are being administered by Delta Dental of
Minnesota. Please direct all correspondence to:
Dental Procedures and
Pre-op/Medical Exams
Delta Dental of Minnesota
P.O. Box 330
Minneapolis, MN 55440
Delta Dental of Minnesota is independent from Blue Cross and
Blue Shield of Minnesota. Delta Dental is solely responsible for
administration of its dental products.
When a member comes to your clinic for a pre-op exam for a
dental related procedure, code the exam as a medical pre-op. The
charges will fall under their medical benefits. Providers should
only code as a pre-op exam if they know the procedure will be
covered.
Blue Cross Blue Shield of Minnesota Provider Policy and Procedure Manual (03/06/12)
11-5

Chapter 11
Coding Policies and Guidelines
(Durable Medical Equipment)
Table of Contents
Durable Medical Equipment (DME) Definition.................................................................. 11-2
Enrollment Requirements when Providing Services to MHCP Subscribers .......................11-2
Prior Authorization Requirements ....................................................................................... 11-3
Ineligible Items ....................................................................................................................11-4
DME Rental Guidelines.......................................................................................................11-5
Medicare Advantage DME Rental Guidelines .................................................................... 11-5
Waivers and Upgraded/Deluxe DME ..................................................................................11-7
Waiver Claim Submission ................................................................................................... 11-7
Sample Waiver Form ........................................................................................................... 11-8
DME Coding........................................................................................................................ 11-8
Sales Tax..............................................................................................................................11-9
Handling/ Conveyance......................................................................................................... 11-9
Claims Filing Requirements ................................................................................................ 11-9
Hearing Aids ......................................................................................................................11-10
Oxygen and Oxygen Aiding Equipment (includes ventilators).........................................11-12
Portable Oxygen Billing ....................................................................................................11-12
Coding Modifiers............................................................................................................... 11-13
DME Repairs and Maintenance (Excluding Oxygen Equipment).....................................11-14
Replacement of Purchased Equipment .............................................................................. 11-14
Billing for Supplies............................................................................................................ 11-15
Rental Unit Submission .....................................................................................................11-16
Hospital DME Providers.................................................................................................... 11-16
DME/Supply Internet Purchases........................................................................................ 11-17
E0935 Rental Guides ......................................................................................................... 11-17
Pharmacies Submitting DME Claims ................................................................................11-17
DME and Specialty Pharmacy Billed through the BlueCard ® Program............................11-18
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 08/15/2012) 11-1

Coding Policies and Guidelines (Durable Medical Equipment)
Durable Medical
Equipment (DME)
Definition
Enrollment
Requirements when
Providing Services to
MHCP Subscribers
11-2
Blue Cross and Blue Shield of Minnesota (Blue Cross) defines
DME as equipment and related health care supplies and services
that are:
able to withstand repeated use; and
used primarily for a medical purpose; and
generally not useful in the absence of illness or injury; and
determined to be reasonable and necessary; and
prescribed by a physician; and
represents the most cost-effective alternative.
Effective January 1, 2012, Minnesota Statutes Section 256B.0625
requires that DME and Orthotic & Prosthetic (O&P) providers be
enrolled as Medicare providers if the provider provides services to
individuals enrolled in Minnesota Health Care Programs (MHCP).
This includes subscribers enrolled in Blue Advantage (PMAP,
MinnesotaCare and Minnesota Senior Care Plus) and
SecureBlue SM (HMO SNP). Enrollment in Medicare requires that
providers accept Medicare’s assignment of claims and payment for
services. According to the Centers for Medicare & Medicaid
Services (CMS), DME and O&P providers are enrolled as
Medicare providers after their Medicare enrollment application has
been completed and approved by Medicare.
Minnesota Statutes Section 256B.0625, subd. 31 reads, in part, as
follows: “Medical supplies and equipment… (b) Vendors of
durable medical equipment, prosthetics, orthotics, or medical
supplies must enroll as a Medicare provider.”
Blue Cross participating providers agree to comply with all
applicable state and federal laws, rules, regulations, orders and
requirements. Therefore, all DME and O&P participating
providers who provide services/products to MHCP and Medicare
subscribers must be enrolled with Medicare per Minnesota Statutes
Section 256B.0625.
In addition to the changes noted above, Blue Cross requires all
DME and O&P providers to submit the ordering and referring
provider information via loop 2420E in the electronic transaction.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/15/2012)

Prior Authorization
Requirements
Coding Policies and Guidelines (Durable Medical Equipment)
Fax all prior authorization requests for Blue Cross subscribers
using the Prior Authorization Request for DME form (F5893-R02)
to (651) 662-2810. Blue Cross will approve or deny prior
authorization requests based on a subscriber's contract benefits and
the criteria defined in applicable medical policies. Prior
authorization requests should be submitted by the DME supplier
who will be providing the equipment and should include the
appropriate HCPCS code(s).
For questions about prior authorizations, call (651) 662-5270 or
1-800-528-0934 (choose option 2, then option 4). Providers can
also fax prior authorization questions to (651) 662-2810.
Subscribers should call the number on the back of their subscriber
ID card for customer service if they have questions.
To access the most current medical policies including DME prior
authorization (PA) list go to providers.bluecrossmn.com >
“Tools and Resources” > Medical Policy.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/15/2012)
11-3

Coding Policies and Guidelines (Durable Medical Equipment)
Ineligible Items The following lists of some items that are considered ineligible
DME. There is no need to submit prior authorization requests for
ineligible items.
Abdominal support belts
for pregnant women
Adaptive eating
equipment
Air conditioners
Air filters
Back huggers
Balls for therapy
Bedpans and urinals
Biofeedback device,
purchase
Blood pressure cuffs and
accessories
Car seats
Computer software &
hardware
Copes scoliosis brace total
recovery program
Croup tent
Cryocuff (icing device)
Drionic devices (sweating
devices)
11-4
Note: This is not an all-inclusive list. (For Medicaid products, see
DHS website for Minnesota Health Care Programs manual.)
Elevators/stairlifts
Exercise equipment (e.g.
bicycles, tricycles,
treadmills and ski
machines)
Feeding chairs
Floor sitters
Formula, infant
Grab bars
Heating pads
Home monitors
Incontinence supplies (e.g.
diapers, underpants,
underpads, Attends)
Lifeline medical alert
Maternity belts
Overbed tables
Positioning aids (e.g.
bolsters, wedges)
Reachers
Roman chairs
Scales
StimMaster E4000
Telephone communication
device (TTDY)
Thera cane
Tub stool or bench
Vehicle modifications
(hand controls, lifts and
car seats)
Vitrectomy, seated
support system (special
chair for eye surgery
patients)
Wheelchair vehicle
lift/ramps
Whirlpools/Jacuzzi/hot
tubs
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/15/2012)

Coding Policies and Guidelines (Durable Medical Equipment)
DME Rental Guidelines Most DME can only be rented for 10 months. DME is considered
purchased after 10 months of rental payments. Ten months rental
for a particular item equals Blue Cross allowed amount for the
purchase price of that item. No additional claims for rental or
purchase of the same device should be submitted after the Blue
Cross allowed amount for the purchase price of that item has been
met.
Medicare Advantage
DME Rental Guidelines
The following items are rental only:
Ventilators
Negative-pressure ventilators
CPM machines
Oximeters
Airway-pressure monitors oxygen concentrators
Medicare Advantage DME claims are subject to Original Medicare
claims processing supplier guidelines. The total number of months
of capped rental DME payment is based on the date of service of
the initial capped rental. In all instances, when billing capped
rentals, use the modifiers as outlined in Medicare’s claims
processing manuals.
For capped rentals, Blue Cross will reimburse monthly rental
claims of continuous use for 13 months. The option to purchase
at the 10 th month of rental no longer applies. After 13 months
of continuous rental, ownership of the equipment is transferred
to the subscriber. The first three rental months will be
reimbursed based on the fee schedule amount. For the
remaining rental months, the fee schedule amount will be
reduced by 25 percent.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/15/2012)
11-5

Coding Policies and Guidelines (Durable Medical Equipment)
Medicare Advantage
DME Rental Guidelines
(continued)
11-6
Electric wheelchairs are an exception to this process. A
purchase option must be given to the subscriber at the time the
electric wheelchair is first provided, regardless of the initial
date of service. Blue Cross recommends a prior authorization
be completed for all wheelchair purchases. If the subscriber
chooses to rent and not purchase the electric wheelchair at the
time the item is provided, the length of rental (13 or 15
months) is dependent upon the date of the initial rental.
In accordance with Medicare, maintenance and service will be
allowed on capped rental and where the subscriber chose the
rental option only. Providers should bill for maintenance and
services using the appropriate HCPCS code and the modifier –
MS.
For capped rentals bill for replacement or repair using modifier
RA or RB with the HCPCS code for the item serviced.
RA Replacement of a DME, orthotic or prosthetic item.
RB Replacement of a part of DME, orthotic or prosthetic item
furnished as part of a repair.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/15/2012)

Waivers and
Upgraded/Deluxe DME
Waiver Claim
Submission
Coding Policies and Guidelines (Durable Medical Equipment)
The following is Blue Cross’ policy for provision of upgraded or
deluxe equipment. This policy does not apply to Minnesota Health
Care Program subscribers because only medically necessary DME
may be provided and billed to these subscribers.
Providers may bill subscribers for an equipment upgrade or deluxe
charge if a waiver is on file and the DME charges are billed
correctly to Blue Cross. Blue Cross will continue to reimburse
only for medically necessary standard DME. Providers must ask
for a signed, written waiver that includes the cost for the deluxe
features or upgrade. (A sample waiver form follows.)
The waiver must state ALL of the following:
The standard piece of equipment or least costly alternative was
offered to the subscriber; and
The subscriber is aware and agrees that Blue Cross will only
pay the standard allowance; and
The subscriber will be responsible for the deluxe or upgrade
charge in addition to his or her contractual obligation
Providers must keep all signed waivers on file. Do not send waiver
forms to Blue Cross. Blue Cross reserves the right to request
waiver forms from a provider's office when necessary.
Two lines of services must be billed. The first line will include the
HCPCS code and the charge for the standard (non-deluxe)
equipment with the GK modifier (in addition to any other
appropriate modifier). This dollar amount will be subject to
contract benefits and usual and customary reductions.
The second line must include the same HCPCS code with the -GA
modifier (waiver of liability statement issued as required by payer
policy, individual case) and the amount charged for the upgrade or
deluxe feature.
For example:
E0202 NU GK $550.00 (standard, charge that will be subject to
standard allowance and subscriber contract benefits)
E0202 GA $150.00 (deluxe/upgrade charge that will be denied
as subscriber liability)
The -GA modifier must be submitted as the first modifier on the
second service line. Other applicable modifiers should be
submitted on the first service line only.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/15/2012)
11-7

Coding Policies and Guidelines (Durable Medical Equipment)
Sample Waiver Form As a participating provider with Blue Cross, we are obligated to
notify you of services that are medically unnecessary. This
notification will allow us to hold you financially responsible for
the upgrade to the DME that you are purchasing.
We have offered you the standard _______________________
(list type of equipment)
at the customary price of $________________ .
We have informed you of the least costly alternative, which is
the charge for the upgrade or deluxe features is $___________ .
By signing and dating this waiver, you are acknowledging that:
You are aware of and agree that Blue Cross will allow only
standard equipment.
Only the allowed amount for the standard equipment will apply
to deductible and coinsurance amounts.
You will be financially responsible for the deluxe or upgrade
charge.
The upgrade charge is in addition to any contractual
obligations you have such as deductible and coinsurance
amounts.
Signature ____________________________ Date: _________
DME Coding DME suppliers and others who bill supply items should use
HCPCS level II codes. Our research shows that codes E1399 and
K0108 are used excessively and incorrectly. These should be used
ONLY when there is no code listed in the HCPCS manual for the
equipment. Do not use this code for supplies or equipment that can
be coded with a specific code or combination of codes.
11-8
Unlisted codes (such as K0108 or E1399) require submission of a
narrative describing the equipment along with the Manufacturers
Suggested Retail Price (MSRP).
Additional identification of the product or supply can be entered in
the electronic claim in the NTE segment:
837P: Loop 2400, Segment NTE
837I: Loop 2300, Segment NTE
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/15/2012)

Coding Policies and Guidelines (Durable Medical Equipment)
Sales Tax Sales tax should generally be included in your charge for the item
and not reported separately. If submitted, sales tax must be
reported using code S9999 for the tax and must be billed on the
same claim as the related taxable service. Code S9999 will be
denied as provider liability.
Handling/
Conveyance
Claims Filing
Requirements
Handling, conveyance, and/or any other service in connection with
the implementation of an order involving devices (code 99002) is
not separately reimbursable. These charges should be included in
charge for the item.
1. Use the 837P claim form to report your services to Blue Cross.
To obtain forms, please refer to Chapter 8 – Claims Filing in
this manual.
2. Submit ICD-9-CM codes to report an appropriate diagnosis for
your patient.
3. Use HCPCS level II codes to report your services.
4. Appropriate modifiers are required to indicate rental or
purchase of DME, e.g., NU, RR.
5. The place of service must be a valid CMS two-digit place of
service code.
6. Submit units based on narrative description.
DME providers and skilled nursing facilities billing for place of
service 31, 32, or 33, are required to submit an Explanation of
Medicare Benefits (EOMB) for their services unless the provider
has opted out of Medicare. If the provider has opted out then the
provider will need to include the opt-out letter with claims
submitted. Any other place of service does require an EOMB. This
applies only to Medicare recipients.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/15/2012)
11-9

Coding Policies and Guidelines (Durable Medical Equipment)
Hearing Aids Hearing aids are generally not covered for most contracts.
11-10
Minnesota Health Care Programs hearing aids
Blue Cross uses the MHCP Hearing Aid Volume Purchase
Contract (which contains the MHCP Hearing Aid Contract) as the
base Medical Assistance Fee Schedule. Blue Cross will follow the
non-covered code list contained in the MHCP Hearing Aid
Contract and the DHS supply limits.
Products affected
The following MHCP products are affected:
Blue Advantage (PMAP/GAMC, MSC & MSC+)
MinnesotaCare
SecureBlue
MHCP Hearing Aid Volume Purchase Contract
The hearing aid service provider must dispense the hearing aid
according to the hearing aid exam, selection and prescription of the
otolaryngologist and audiologist.
For accurate claims processing, the provider will need to submit an
attachment that includes the manufacturers’ specifications.
Providers should utilize the information contained in the current
MHCP contracts, including manufacturer, model name and model
number. This information will need to be included in the
attachment when the claim for reimbursement is submitted. Blue
Cross will verify that the hearing aid billed is a covered benefit for
the subscriber and will apply the current MHCP Hearing Aid
Volume Purchase Contract pricing for reimbursement. Items not
included in this pricing will defer to the DHS Medical Assistance
standard fee schedule or the Blue Cross standard fee schedule, as
applicable.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/15/2012)

Hearing Aids
(continued)
Website
Coding Policies and Guidelines (Durable Medical Equipment)
The current MHCP Contract Pricing can be found at:
http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNA
MIC_CONVERSION&RevisionSelectionMethod=LatestReleased
&dDocName=id_010724
Prior Authorization
If the subscriber requires a hearing aid that is not listed on the
DHS Volume Hearing Aid Purchase Contract, a prior authorization
may be submitted for review of coverage to the prior authorization
fax line at (651) 662-2810. Please include the following
information in the request:
Audiologic recommendations, including:
Written recommendations for hearing aid(s), including the
manufacturer specifications
Follow-up plan for determining the effectiveness of the hearing
aid
Audiogram or reason why this was not obtained
History of previous hearing aid use
Pure tone average
Reason why a standard hearing aid on the Volume Hearing Aid
Purchase Contract is not appropriate for this subscriber
Binaural Hearing Aid Units
Binaural hearing aid codes should be submitted with 1 unit only.
The set allowance reflects two hearing aids.
When submitting a charge for hearing aid repair, use HCPCS code
V5014. Coverage of hearing aids, services and supplies is
contractually based.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/15/2012)
11-11

Coding Policies and Guidelines (Durable Medical Equipment)
Oxygen and Oxygen
Aiding Equipment
(includes ventilators)
Portable Oxygen
Billing
11-12
Oxygen and oxygen aiding equipment are defined as the following
items:
Oxygen
Ventilators
Negative-Pressure Ventilators
Oximeters
Large-Volume Air Compressors
Airway-Pressure Monitors (excluding CPAP)
Oxygen Concentrators and Oxygen Conservers
Oxygen equipment is reimbursed on a rental basis only, as long as
the equipment is medically necessary.
Oxygen contents will be reimbursed separately only when the
subscriber owns an oxygen system, or rents or owns only a
portable oxygen system.
The units billed for the following codes should never exceed
one (1) per one-month-date range based on the code narrative:
E0443 - Portable oxygen contents, gaseous (for use only with
portable gaseous systems when no stationary gas or liquid
system is used), one month's supply = 1 unit
E0444 - Portable oxygen contents, liquid (for use only with
portable liquid systems when no stationary gas or liquid system
is used), one month's supply = 1 unit
At this time the Department of Human Services (DHS) has
different unit submission guides for billing units for E0443-E0444;
however, those guidelines may be used only for Public Program
claims.
In addition to the oxygen contents only codes, E0443 and E0444,
the equipment rental or purchase fees are billed separately as
appropriate, with the corresponding gaseous or liquid system code
as follows:
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/15/2012)

Portable Oxygen
Billing (continued)
Code Definition
Coding Policies and Guidelines (Durable Medical Equipment)
E0430 Portable gaseous oxygen system, purchase; includes
regulator, flowmeter, humidifier, cannula or mask,
and tubing
E0431 Portable gaseous oxygen system, rental; includes
portable container, regulator, flowmeter, humidifier,
cannula or mask, and tubing
E0434 Portable liquid oxygen system, rental; includes
portable container, supply reservoir, humidifier,
flowmeter, refill adaptor, contents gauge, cannula or
mask, and tubing
E0435 Portable liquid oxygen system, purchase; includes
portable container, supply reservoir, flowmeter,
humidifier, contents gauge, cannula or mask, tubing
and refill adaptor
Coding Modifiers Blue Cross requires all DME providers to submit procedure code
modifiers to differentiate rental, purchase and repair or
replacement of DME. Modifiers include the following:
Rental Modifiers:
BR The beneficiary has been informed of the purchase and
rental options and has elected to rent the item
LL Lease/rental (Use the LL modifier when DME equipment
rental is to be applied against the purchase price)
RR Rental (Use the RR modifier when DME is to be rented)
Purchase Modifiers:
BP The beneficiary has been informed of the purchase and
rental options and has elected to purchase the item
NR New when rented. (Use the NR modifier when DME which
was new at the time of rental is subsequently purchased.)
NU New equipment
RA Replacement of a DME, orthotic or prosthetic item
RB Replacement of a part of DME, orthotic or prosthetic item
furnished as part of a repair
Note: The modifiers BU or UE are not recognized in processing.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/15/2012)
11-13

Coding Policies and Guidelines (Durable Medical Equipment)
DME Repairs and
Maintenance
(Excluding Oxygen
Equipment)
Replacement of
Purchased Equipment
11-14
Repair of rental DME is not covered.
Exception:
For Medicare Advantage subscribers with a capped rental item
with an initial date on and after January 1, 2006, repair may be
billed using modifier -RA or -RB with the HCPCS code for the
item serviced.
RA Replacement of a DME orthotic or prosthetic item.
RB Replacement of a part of DME orthotic or prosthetic item
furnished as part of a repair.
Repair may be allowed for purchased DME. To submit repair,
report the HCPCS code for the DME being repaired with the –
RB modifier. Submit K0739 (repair or nonroutine service for
DME other than oxygen equipment requiring the skill of a
technician, labor component, per 15 minutes) or K0740 (repair
or nonroutine service for oxygen equipment requiring the skill
of a technician, labor component, per 15 minutes) on a separate
line. Include the appropriate number of units (one per 15
minutes). The cost of the repair (including parts and loaner fee)
should not exceed our allowable for the purchase of the
equipment.
Charges for maintenance of DME are not covered.
Maintenance would be indicated with the –MS modifier.
Exception:
For Medicare Advantage subscribers, maintenance and service will
be allowed on capped rental with initial rental dates of service
prior to January 1, 2006, and where the subscriber chose the rental
option only.
Blue Cross’ policy is to pay for replacement of DME, due to
normal use and wear, every five (5) years, unless unusual
circumstances necessitate replacement of an item sooner than five
years.
Replacement of obsolete or inoperable DME equipment, which has
been purchased, is subject to the same prior authorization
guidelines as the purchase of the original equipment.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/15/2012)

Coding Policies and Guidelines (Durable Medical Equipment)
Billing for Supplies Supply items should be submitted with the HCPCS Level II code
that most appropriately describes the item. Unlisted supply codes
should be used only if there is no other code that describes the
item. A narrative must be submitted with every unlisted code.
Supplies are generally allowed separately only in conjunction with
approved home health care. Reimbursement for supplies used in
the office is already included in the overhead component of the
professional service (such as an E/M). Office supplies, such as, but
not limited to, Betadine or alcohol wipes, will be denied.
Payment for supplies is based per narrative description (e.g., each,
per pair, per 100, etc.). It is necessary to identify the total number
of each supply in the “units” field of the 837P claim format.
It is important to assure the units submitted correctly correspond to
the code chosen to ensure appropriate reimbursement. For
example, disposable gloves can be reported per 100 (a single box)
or per pair. Code A4927 reflects billing per 100. HCPCS code
A4930 reflects billing per pair. The unit descriptions for each code
differ significantly.
Following is the narrative for each glove code along with a coding
example:
Code: A4927 Narrative: Glove, non-sterile, per 100
Example: One 100-count box of non-sterile gloves, submit
1 unit in the units field on the 837P claim format.
Code: A4930 Narrative: Gloves, sterile, per pair
Example: One 100-count box of sterile gloves, submit 50 units
in the units field on the 837P claim format.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/15/2012)
11-15

Coding Policies and Guidelines (Durable Medical Equipment)
Billing for Supplies
(continued)
Gloves are restricted to home use only (for approved home health,
home infusion, or home dialysis services). Eligibility for
reimbursement is subject to subscriber benefits.
The following quantities of ostomy and urology-related supplies
are considered to be reasonable for a monthly (30-day) period.
When quantities in excess of these amounts are supplied to the
same patient for use during the same month, the claim(s) must
contain an explanation of the medical necessity for such quantities.
If the documentation is not on the claim, there may be a delay in
processing the claim or the claim may be denied.
Indwelling catheters - two per month
Catheter insertion trays - two per month
Sterile irrigation tray/kit - four per month
Irrigation syringe, bulb or piston - four per month
Bottles of irrigation solution - four per month
Bedside drainage bags - four per month
Leg drainage bags - four per month
Bedside drainage bottle, rigid or expendable - one per month
Leg strap, foam or fabric - one per month
Urinary catheters (straight catheter) - 31 per month
Ostomy Pouches - 70 per month
If a subscriber signs a waiver accepting responsibility for supplies
billed in excess of recommended guides, bill two lines of service.
The first line will include the HCPCS supply code and the second
line should be submitted with the same HCPCS code with a –GA
modifier. See “Waivers and Upgraded/Deluxe DME” for
additional waiver sample and submission information.
Rental Unit Submission Service counts must be submitted on a monthly basis only and
generally submitted as one (1) service per month, instead of 30
units or services. Do not submit claims for more than a thirty-day
supply of any related supplies. Rental is on a monthly basis only.
Hospital DME Providers Hospital DME providers are required to bill DME on an 837I
claim form.
11-16
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/15/2012)

DME/Supply Internet
Purchases
Coding Policies and Guidelines (Durable Medical Equipment)
DME or supplies purchased from Internet auction sites (such as e-
Bay) or private parties are generally not covered. If a DME supply
company is the actual supplier, that provider’s number will be
assigned and the claim will be processed per the subscriber’s
benefits. If the provider is not a DME/supply company (e.g.,
private party, estate sale), the claim will be denied.
E0935 Rental Guides Continuous passive motion devices are usually used only for a
short period of time during a patient’s recovery period. Therefore,
the HCPCS code E0935 (continuous passive motion exercise
device for use on knee only) is assigned a daily rental allowance
and it limited to 21 days of rental. Submit one unit for each day of
rental. For example, if the device is rented for 14 days, indicate 14
in the unit field.
Pharmacies Submitting
DME Claims
Aware agreement
The Aware Agreement states: “Provider shall provide Health
Services to Subscribers for eligible Prescription Drugs which are
authorized by a valid prescription.” This section also includes the
dispensing of DME to Blue Cross subscribers.
Pharmacy responsibilities
It is the responsibility of the participating pharmacy to submit the
claims for all such eligible services to Blue Cross on behalf of the
subscriber. The pharmacy may bill subscribers for appropriate
subscriber liability amounts as detailed in the provider service
agreement. This process allows for the proper adjudication of the
claim by Blue Cross in order to correctly determine the applicable
deductible and/or coinsurance amounts that may be due from the
subscriber. After the claim is processed by Blue Cross, you will be
notified of the proper amount to bill the subscriber, if any balance
remains due from the subscriber.
It is also the responsibility of all participating providers to abide by
all other terms and provisions of the agreement including, but not
limited to, the administration of the coordination of benefits
provisions.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/15/2012)
11-17

Coding Policies and Guidelines (Durable Medical Equipment)
DME and Specialty
Pharmacy Billed
through the BlueCard ®
Program
11-18
Blue plans* may contract with providers outside of their exclusive
service area for services provided to local and BlueCard
subscribers within their own service area for DME and selfadministered
specialty pharmacy. Blue plans may not contract for
such services for their subscribers who receive services outside of
their service area.
DME
DME providers should file claims to the Blue plan in whose
service area the equipment or supplies were shipped or purchased
if the location was a retail store. For example, if a DME device
was delivered to a subscriber in Massachusetts, then the claim
should be filed with Blue Cross and Blue Shield of Massachusetts.
The claim will be reimbursed based on provider’s participation
status with that Blue plan.
Specialty Pharmacy
Self-administered specialty pharmacy providers should file the
claim to the Blue plan where the ordering physician is located. The
claim will be reimbursed based on provider’s participation status
with that Blue plan.
* Each Blue plan is an independent licensee of the Blue Cross and
Blue Shield Association
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/15/2012)

Chapter 11
Coding Policies and Guidelines
(Home Health, Home Infusion, Hospice)
Table of Contents
Definitions............................................................................................................................11-2
Prior Authorization .............................................................................................................. 11-2
Home Health ........................................................................................................................11-3
Elderly Waiver Program ...................................................................................................... 11-4
Referrals and Prior Authorization........................................................................................ 11-6
Adult Day Care Bath Services ........................................................................................... 11-11
RAP Claim Submission ..................................................................................................... 11-11
Home Infusion ................................................................................................................... 11-12
Medicare Primary with Blue Cross Secondary..................................................................11-14
Hospice ..............................................................................................................................11-15
Rules and Regulations........................................................................................................11-15
Hospice Billing for Medicare Products..............................................................................11-17
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (07/12/12) 11-1

Coding Policies and Guidelines (Home Health, Home Infusion, Hospice)
Definitions Home Health
Home health care is care provided in a patient's home by qualified
personnel.
Home Infusion
Home infusion is the administration of medications or nutrition
intravenously or through a feeding tube.
Hospice
Hospice care is a concept of care that provides palliative care
(rather than curative care) to a terminally ill patient and family.
Prior Authorization All home health services require prior authorization. Hospice
services require prior authorization only for FEP members and
notification for MHCP members. Prior authorization is required
for the following home infusion services:
11-2
Blood factor products
IVIG
Synagis
Home health, blood factor, IVIG and Synagis prior authorization is
performed by:
Utilization Management
Route code: R4-72
(651) 662-5520
1-888-878-0139 ext. 25520
Fax: (651) 662-1004
Address:
P.O. Box 64265
St. Paul, MN 55164-0265
For Government Program members
Utilization Management
Route code: R348
(651) 662-5540
1-800-711-9668
Fax: 651-662-4022 or 1-866-800-1665
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (07/12/12)

Coding Policies and Guidelines (Home Health, Home Infusion, Hospice)
Home Health Examples of home health care services requiring review include:
skilled home nursing visits, home health aid services, home social
worker visits, physical therapy, occupational therapy, speech
therapy and personal care attendants.
Coverage of services is subject to contract benefits and
limitations.
Services must be skilled versus non-skilled or custodial.
Services must be intermittent and of a medical nature.
Home health care must be ordered in writing by a physician
and performed by a Medicare certified/JCAHO approved home
health agency.
Note: Personal care attendants are not eligible for coverage under
most health plans, with the exception of Public Programs.
Services must be submitted on an 837I claim form. The
appropriate revenue code(s) should be submitted for the services
supplied. Associated HCPCS codes must be submitted on each line
or the line may be denied for additional information.
Home Health revenue code categories are:
055X Home Health (HH) - Skilled Nursing
056X Home Health (HH) - Medical Social Services
057X Home Health (HH) - Aide
058X Home Health (HH) - Other Visits
059X Home Health (HH) - Units of Service
060X Home Health (HH) – Oxygen
Prior authorization is recommended for all members, regardless of
plan. For members who are eligible for elderly waiver services, the
home care agency should coordinate with the member’s care
coordinator for home care services. The authorization number
provided by Blue Cross must be entered in the REF segment on the
electronic 837I.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (07/12/12)
11-3

Coding Policies and Guidelines (Home Health, Home Infusion, Hospice)
Elderly Waiver
Program
11-4
The statewide Elderly Waiver Program (EW) is available to
members of Blue Advantage MSC+ and SecureBlue SM (HMO
SNP). Blue Plus will review all Medicaid and Medicare home care
requests and determine the number of visits based upon medical
necessity, Medicare, and state plan guidelines. This is applicable to
all members receiving Medicaid and Medicare home care services
including those on Elderly Waiver.
Home care agencies contact the member’s care coordinator for
consultation regarding the member’s plan of care. The care
coordinator will need to fax in the 6.04.01 Recommendation for
Authorization of MA Home Care Services for members open to a
home and community based disability or form 6.04.03 Home Care
Services Recommendation-Non Disability to request Blue Plus to
review the services.
Blue Plus will obtain medical necessity information from the home
care agency and will review the information submitted and make a
coverage determination within 10 days of receipt of the request.
When a determination is made, Blue Plus will notify the member
and the home care provider via a letter of the outcome.
Blue Plus will fax the 6.04.01 or 6.04.03 form back to the care
coordinator for their records and case mix cap management.
PCA Services
Blue Cross and Blue Plus contracts with Personal Care Provider
Organizations (PCPO) and PCA (Personal Care Assistant) Choice
providers as part of our Government Programs Specialty Network.
PCA services are eligible only for reimbursement under certain
Public Program contracts. PCA services may also be furnished
through a contracted home health agency. The following
information describes the programs, eligible services and claims
submission requirements.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (07/12/12)

Elderly Waiver
Program (continued)
Coding Policies and Guidelines (Home Health, Home Infusion, Hospice)
Minnesota Health Care Programs
Group numbers for members who have coverage with Minnesota
Health Care Programs are as follows:
Product Name ID #s / Group Numbers
Blue Advantage
(PMAP and MSC+)
MinnesotaCare
Expanded
ID #s begin with “XZG8” / All group
numbers that begin with PP0
ID #s begin with “XZG8” / All group
numbers that begin with PP1
SecureBlue ID #s begin with “XZS8” / All group
numbers that begin with PP2
Program Purpose
Minnesota’s PCA program is designed to support people of all
ages with disabilities to live independently in the community.
PCAs provide home-based services to people who need help with
activities of daily living and health-related functions (under
direction of an RN or qualified professional such as a Social
Worker or Psychologist). PCAs may provide hands-on assistance,
supervision, cueing, redirection and intervention for behavior
including observation and monitoring. PCA services can be linked
to medical or behavioral health diagnoses and are considered a
home care service.
Eligibility for PCA Services
There are three basic requirements for eligibility:
1. The patient must be eligible for, or receiving, Prepaid Medical
Assistance Program (PMAP) or MinnesotaCare Expanded
benefits (for pregnant women or children under age 21).
2. The patient must have a physician’s statement of need stating
that PCA services are medically necessary.
3. The patient must be able to make decisions about their care or
have a person designated as a Responsible Party (RP) who can
make decisions about the patient’s care. (The RP must
participate in the planning and directing of PCA services. The
RP cannot be the PCA and must be 18 years or older, available
for the patient and/or PCA, and monitor care a minimum of
one time per week.)
Note: General Assistance Medical Care (GAMC) members and
adults enrolled in MinnesotaCare (except pregnant women)
are not eligible for PCA services. CareBlue SM (HMO SNP)
members are eligible for PCA services but their services are
paid by the State of Minnesota and not BluePlus.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (07/12/12)
11-5

Coding Policies and Guidelines (Home Health, Home Infusion, Hospice)
Referrals and Prior
Authorization
11-6
Statement of Need for PCA Services
In accordance with Minnesota Statute 256B.0655, a physician’s
statement of need must be obtained before the start of services and
annually thereafter. The statement of need must include the
member’s diagnosis and condition for which the PCA services are
needed. The statement of need must also be utilized any time there
is a change in the member’s condition that results in a change in
the level of PCA services.
The Minnesota Council of Health Plans has collaborated with all
health plans to develop a universal statement of need form for the
PCA program. This statement of need form is posted on the MN
Council of Health Plans website at www.mnhealthplans.org.
Blue Cross requires that the form be completed prior to the start of
any PCA services. Services must be provided by a par provider.
Process for Initiating PCA Services
1. Prior to rendering PCA services to a Blue Plus Public
Programs member, providers should contact the member’s case
manager, care coordinator or IHM Utilization review area as
follows:
For Blue Advantage PMAP members, contact the
Government Programs Integrated Health Management
Intake at (651) 662-5540 or 1-800-711-9668.
For SecureBlue and MSC+ members, contact the member’s
county coordinator, if known, to request PCA services. For
assistance in locating the member’s county care
coordinator, contact Government Programs Integrated
Health Management Intake at (651) 662-5540 or at
1-800-711-9868. SecureBlue members are those members
with Minnesota Senior Health Options (MSHO) coverage
through Blue Plus.
2. An assessment of the member’s need for PCA services will be
completed by a public health nurse, Elderly Waiver case
manager or county care coordinator that has been trained by
the Department of Human Services.
3. Once completed, the PCA assessment should be faxed to
Government Programs Integrated Health Management at
(651) 662-4022 or 1-866-800-1665 for review.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (07/12/12)

Referrals and Prior
Authorization
(continued)
Coding Policies and Guidelines (Home Health, Home Infusion, Hospice)
4. A utilization management nurse will review the request using
the state guidelines for PCA services and make a coverage
determination. A determination will be made within 10 days
from the date the PCA assessment is received by BluePlus.
5. Once a determination has been made, the member, PCA
agency and care coordinator (if applicable) will receive
notification of the amount of services authorized, date spans
covered and an authorization number. If the services have been
denied or reduced, the member’s primary care physician will
also be notified.
Documentation requirements (applies only to providers
employing PCAs)
PCA providers must use a standardized timesheet for all PCAs.
The timesheet must include the following: the start and end time
for each episode of PCA service, the services provided, signature
of the PCA, signature of the member or responsible party, and a
statement that false billing is a federal crime.
PCA individual provider number (applies only to providers
employing PCAs)
DHS assigns Medical Assistance provider numbers to each
individual PCA. Only PCAs who have been issued such a number
by DHS and have evidence of a completed and approved
background study (completed by DHS), shall be considered
eligible providers for the purpose of rendering care to Blue Plus
Minnesota Public Program members. Post-service audits will be
conducted to ensure that the criteria are being met.
When billing an 837P claim format, PCA providers must submit
their individual provider ID in the rendering practitioner fields.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (07/12/12)
11-7

Coding Policies and Guidelines (Home Health, Home Infusion, Hospice)
Referrals and Prior
Authorization
(continued)
11-8
PCA services must be submitted to Blue Plus using one date of
service per claim line. Any claim lines that are submitted with
more than one date of service (date span) will be denied for
improper format. All claim lines should have an individual PCA
associated with the service.
All PCA claim lines (T1019), except for those submitted with the
QP supervision modifier, must include at least one of the
relationship modifiers on each line (UD or U1). All other HCPCS
code and modifier combinations still apply to PCA claims.
Multiple modifiers can be submitted on one line to further identify
services provided. Claims that do not include an appropriate
modifier will be denied. These claims may be reconsidered when
the appropriate modifier is provided.
Participating Home
Health Agencies
Purpose: provide
skilled and nonskilled
care and
supervision
Billing: submit
services on a facility
claim format (837I),
use revenue codes
0570-0579 and
HCPCS code T1019
PCA Code
or Code &
Modifier Code Narrative
Personal Care
Provider
Organization
Purpose: provide
RN/qualified
professional
supervision and
PCA services only
Billing: submit
services on a
professional claim
format (837P) using
the appropriate “T”
HCPCS codes (see
code and modifier
list below)
T1001 Nursing assessment/evaluation
PCA Choice
Providers
Purpose: bill PCA
services for the
member.
Member/RP does all
hiring, training and
supervision of
PCAs.
Billing: submit
services on a
Professional claim
format (837P) using
the appropriate “T”
HCPCS codes (see
code and modifier
list below)
Modifier
Instructions
T1001-52 Same as above The –52 modifier is
submitted to
indicate a service
update.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (07/12/12)

Referrals and Prior
Authorization
(continued)
Coding Policies and Guidelines (Home Health, Home Infusion, Hospice)
PCA Code
or Code &
Modifier Code Narrative
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (07/12/12)
Modifier
Instructions
T1001-U6 Same as above The –U6 modifier is
submitted to
indicate a temporary
service increase.
T1019 Personal care services, per 15
minutes, not for an inpatient or
resident of a hospital, nursing
facility, ICF/MR or IMD, part
of the individualized plan of
care treatment (code may not
be used to identify services
provided by home health aide
or certified nursing assistant)
T1019-TT Same as above The –TT modifier is
submitted to
indicate personal
care assistant PCPO
services at a 1:2
ratio (one assistant
to two patients).
T1019-
HQ
T1019-
UA
Same as above The –HQ modifier is
submitted to
indicate personal
care assistant PCPO
services at a 1:3
ratio (one assistant
to three patients).
Same as above The UA modifier is
submitted to
indicate the services
are for supervision
of a PCA.
11-9

Coding Policies and Guidelines (Home Health, Home Infusion, Hospice)
Referrals and Prior
Authorization
(continued)
11-10
PCA Code
or Code &
Modifier Code Narrative
T1019-
UD
Modifier
Instructions
Same as above The UD modifier is
submitted to
indicate personal
care assistant PCPO
services at a 1:1
ratio (one assistant
to one patient). No
relationship to the
member.
T1019-U1 Same as above The UD modifier is
submitted to
indicate personal
care assistant PCPO
services at a 1:1
ratio (one assistant
to one patient).
Parent/Adoptive
Parent, Sibling,
Adult Child,
Grandparent or
Grandchild of the
member.
T1019-U6 Same as above The U6 modifier is
submitted to
indicate the service
is for a temporary
45-day service
increase.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (07/12/12)

Adult Day Care Bath
Services
Coding Policies and Guidelines (Home Health, Home Infusion, Hospice)
Bath services provided by Adult Day Care providers are a covered
benefit for Public Program members under the following
programs:
SecureBlue – groups beginning with PP2
Minnesota Senior Care Plus (MSC+) – groups beginning with
PP0
These members must also be on an Elderly Waiver program.
Services should be coordinated with the member’s care
coordinator and part of the member’s comprehensive care plan.
The Adult Day Care providers must have record of the individual’s
care plan that documents the necessity for the services. Eligible
providers must be listed on the Minnesota Department of Human
Services website as licensed Adult Day Care providers.
Claim Submission
Submit the claim on the 837P claim format.
Bill code S5100-TF (day care services, adult; per 15 minutes).
Eligible providers may be reimbursed for a maximum of two
units of service per day.
Enter each date of service on a separate line with units of
service for each date.
Reimbursement will be based on the usual pricing methodology
for Public Programs.
RAP Claim Submission Home health providers submitting Medicare RAP (Request for
Anticipated Payment) claims should submit zero charges ($0.00)
with the HIPPS code on the 0023 revenue code line. Claims
submitted with charge amounts other than $0.00 on the 0023
revenue code line will be denied and returned to the provider
without processing.
Products Affected
This change applies to home health RAP claims submitted for the
following Medicare enrollees:
Product Name Member ID alpha prefix
CareBlue XZS
SecureBlue XZS
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (07/12/12)
11-11

Coding Policies and Guidelines (Home Health, Home Infusion, Hospice)
Home Infusion Coverage of services is subject to contract benefits and limitations.
11-12
Home infusion services must be ordered in writing by a physician
and performed by a Medicare certified/JCAHO approved home
infusion agency.
Claim Submission
Submit claims using either the electronic ASC ANSI X 12N
837P format using CPT and HCPCS codes.
Use the Place of Service code 12 (Home) for services provided
in the patient’s home.
Use the Place of Service code 11 or 49 for services provided in
a home infusion suite in the provider’s office.
Professional ID numbers are issued with contracts for all
participating home infusion providers. Individual provider
numbers are not required. As always, reimbursement is subject to
the member’s contract benefits.
Per Diem Payment
The HCPCS “S” codes for home infusion services are based on a
“per diem” reimbursement methodology. The per diem includes all
supplies, care coordination and professional pharmacy services.
The per diem is billed for each day that a patient is on service from
date of admission through date of discharge. Nursing services and
drug products are billed separately from the per diem.
Drugs
Code all drugs with a HCPCS or CPT code. If a specific code is
not available you may use J3490, J7799 or J9999. Provide the
narrative, NDC number and dosage/units supplied. Related NDC
codes for compounded products are itemized using the LIN and
CTP segments.
These claims will require manual review.
Use drug units as described in the HCPCS or CPT description of
the code.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (07/12/12)

Home Infusion
(continued)
Coding Policies and Guidelines (Home Health, Home Infusion, Hospice)
Nursing Services
Code home IV nursing visits lasting up to two hours using CPT
code 99601. Report each additional hour beyond the initial two
with 99602 with the appropriate number of units.
When provided in the infusion suite of a home infusion agency,
code each nursing visit lasting up to two hours using CPT code
99199, with a narrative description. Report each additional hour
beyond the initial two with 99199-52 with the appropriate number
of units, in accordance with the NHIA (National Home Infusion
Association) recommendations for billing.
Catheter Care
Bill catheter care per diems (S5498, S5501, S5502) when provided
as a stand-alone therapy. Insertion by a nurse of a PICC line
(S5522) or midline (S5523) is coded separately from the other
nursing visit code and per diem. Supplies required from nonroutine
catheter procedures such as de-clotting supplies (S5517),
repair kits (S5518), PICC insertion supplies (S5520) and midline
insertion supplies (S5521) are coded separately.
Prior Authorization
Prior authorization is recommended when supplying IVIG, Factor
products, Aldurazyme, Fabrazyme, Synagis or other drugs not yet
identified. A Prior Authorization can be completed using the
standard PA form F1676 R9. For the members insured by a Blue
Cross plan of another state, check the prior authorization
requirements of that state.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (07/12/12)
11-13

Coding Policies and Guidelines (Home Health, Home Infusion, Hospice)
Home Infusion
(continued)
Medicare Primary with
Blue Cross Secondary
11-14
Multiple Therapies
For multiple therapies in the same category done on the same date
of service as primary therapy, append the following modifiers to
the “S” code per diem:
SH- second concurrently administered infusion therapy
SJ- third or more concurrently administered therapy
Notification recommended
Notification to our Case Management department is recommended
for obstetrical patients receiving hydration therapy, tocolytic
therapy (i.e. Terbutaline) or anti-emetic infusion (i.e. Reglan or
Zofran). This serves as notification to Blue Cross that the patient
may need additional support from our staff by calling
(651) 662-5520.
Medicare Supplement policies will only coordinate with the
services that Medicare allows.
Submit the nursing claims to Medicare Part A. The claim may
crossover to Blue Cross and process with your home health
provider number. Agencies who are not certified by Medicare
A should subcontract the nursing portion of the service to
Medicare Part A certified home care agency.
Submit the drugs and supply charges to Medicare Part B. The
claim may crossover to Blue Cross and should process using
your DME provider number.
Verification of the crossover may be done on BLUELINE, or
through our secure website. If the claim is not found, attach the
Medicare EOMB and cover letter to a paper claim and submit
to Blue Cross.
For services that would be denied by Medicare, but may be
allowed by Blue Cross:
A Medicare denial is not required. Submit the claim to Blue
Cross and append the -GY modifier to each line of service.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (07/12/12)

Coding Policies and Guidelines (Home Health, Home Infusion, Hospice)
Hospice Coverage of services is subject to contract benefits and limitations.
Hospice care must be ordered in writing by a physician and
performed by a Medicare certified/JCAHO approved hospice
agency. The member must meet hospice guidelines for admission
into the program.
Services must be submitted on an 837I claim format using a
hospice contracting provider ID number or NPI. The appropriate
revenue code(s) should be submitted for the services supplied.
Hospice revenue codes are 0650-0659.
Prior authorization is required only for FEP members. Effective
April 1, 2012, hospice services require notification for all products
under MHCP to assure proper claims payment.
Rules and Regulations The authorization number provided by Blue Cross must be entered
in the REF segment on the electronic 837I.
The Provider shall have a written eligibility criteria for service
and procedures for referral to other sources that include the
following:
1. Policies shall cover all services provided by the provider
directly or under contract.
2. The policies shall define referrals accepted, admissions of
clients to provider services and the discharge of clients.
3. Criteria of eligibility for the service shall be stated clearly in
reference to such factors as: age groups, geographical area,
hours of service (including policy about 8 to 24 hour service
and weekend service), social and health needs, crises or
emergency services, referral and funding sources.
4. Eligibility criteria that apply to the service shall be available to
community professionals and organizations and persons
applying for the service.
5. There shall be a written policy for making referrals for needed
services that are not available through the provider.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (07/12/12)
11-15

Coding Policies and Guidelines (Home Health, Home Infusion, Hospice)
Rules and Regulations
(continued)
11-16
The provider shall be required to have policies and procedures
which identify:
1. a competent and comprehensive assessment of client healthrelated
needs;
2. that the home health services provided are appropriate to a
client’s identified needs;
3. that an approved plan of care is accurately implemented
through service delivery; and
4. that the client care and treatment, including progress reports
from all disciplines, is correctly documented in an acceptable
clinical record format in a timely manner.
There shall be a written policy explaining procedures for obtaining
referrals from primary care physician’s original signed physician
plan of treatment and subsequent renewals of plan of treatment
consistent with provider’s applicable licensure/certification
requirements.
Demonstration of Internal Continuity of Care/Case
Management shall include the following:
1. The provider shall have policies and procedures to assure the
coordination, integration and continuity of client’s care.
2. There is a written policy statement ensuring the coordination of
all client services delivered by the provider, according to the
plan of care.
3. There is evidence of the provider’s ongoing compliance with
policies and procedures regarding service coordination,
according to the plan of care.
4. The discharge planning process and transfer policies are the
same as those under external continuity of Care/Case
Management.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (07/12/12)

Rules and Regulations
(continued)
Hospice Billing for
Medicare Products
Coding Policies and Guidelines (Home Health, Home Infusion, Hospice)
In addition to the other provisions of the Agreement and these
Rules and Regulations, the following special provisions will
apply when providing home health services to members of
Blue Cross’ long-term care coverage plans:
1. The provider agrees to request prior authorization of home
health services prior to the commencement of such services.
2. If the member contract includes coverage for medically
necessary, non-emergency medical transportation, the provider
agrees to arrange for and to obtain prior authorization for such
transportation.
Products Affected
SecureBlue (except for members who do not have Medicare
coverage)
CareBlue (except for members who do not have Medicare
coverage)
SecureBlue Medicare Hospice Group Numbers
All claims for members with these group numbers that are
submitted to Blue Cross with provider specialty B5 (inpatient and
home hospice) and all claims for services related to the terminal
illness will be denied indicating that all claims should be sent to
RHHI.
PP245-ZA PP245-ZC PP245-ZE PP245-ZF PP245-ZM PP245-ZR PP245-ZS PP245-ZV PP245-ZW
PP260-ZA PP260-ZC PP260-ZE PP260-ZF PP260-ZM PP260-ZR PP260-ZS PP260-ZV PP260-ZW
PP261-ZA PP261-ZC PP261-ZE PP261-ZF PP261-ZM PP261-ZR PP261-ZS PP261-ZV PP261-ZW
PP262-ZA PP262-ZC PP262-ZE PP262-ZF PP262-ZM PP262-ZR PP262-ZS PP262-ZV PP262-ZW
PP280-ZA PP280-ZC PP280-ZC PP280-ZF PP280-ZM PP280-ZR PP280-ZS PP280-ZV PP280-ZW
PP281-ZA PP281-ZC PP281-ZE PP281-ZF PP281-ZM PP281-ZR PP281-ZS PP281-ZV PP281-ZW
PP282-ZA PP282-ZC PP282-ZE PP282-ZF PP282-ZM PP282-ZR PP282-ZS PP282-ZV PP282-ZW
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (07/12/12)
11-17

Coding Policies and Guidelines (Home Health, Home Infusion, Hospice)
Hospice Billing for
Medicare Products
(continued)
11-18
CareBlue Medicare Hospice Group Numbers
All claims for members with these group numbers that are
submitted to Blue Cross with provider specialty B5 (inpatient and
home hospice) and all claims for services related to the terminal
illness will be denied indicating that all claims should be sent to
RHHI.
PP301-ZA PP301-ZM PP301-ZP PP301-ZQ
PP303-ZA PP303-ZM PP303-ZP PP303-ZQ
PP305-ZA PP305-ZM PP305-ZP PP305-ZQ
PP313-ZA PP313-ZM PP313-ZP PP313-ZQ
Hospice Billing
Members who have elected Medicare hospice benefits can be
identified by their group number for SecureBlue and CareBlue.
The hospice benefit for all Medicare plans administered by Blue
Cross is maintained through the Regional Home Health and
Hospice Medicare Intermediary (RHHI).
SecureBlue/CareBlue Specific Processing
All claims submitted to Blue Cross with provider specialty B5
(inpatient and home hospice) will be denied indicating that all
claims should be sent to RHHI for consideration.
Claims for all other provider specialties for services related to the
terminal illness should be submitted to Medicare for primary
consideration. If submitted to Blue Cross, these claims will be
denied indicating that all claims related to the terminal illness
should be submitted to Medicare for primary consideration. If the
provider needs to bill for a service never covered by Medicare (for
example, special or common carrier transportation or services with
HCPCS codes that begin with alpha characters H, S or T) these
services can be billed to Blue Cross directly.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (07/12/12)

Hospice Billing for
Medicare Products
(continued)
Coding Policies and Guidelines (Home Health, Home Infusion, Hospice)
Claims submitted with a GV modifier indicate services were
provided by a provider not reimbursed through the hospice
provider. These claims need to be submitted to Medicare for
primary consideration. If the claim is submitted to Blue Cross
without Medicare payment information, the claim will be denied
requesting this information. If Medicare payment information is
submitted on the claim, then the SecureBlue/CareBlue products
will consider payment for the services as the secondary payer.
Institutional room and board for SecureBlue or CareBlue nursing
home members is paid by the Minnesota Department of Human
Services (DHS). Nursing facility room and board claims should be
submitted to DHS for payment. Claims received by Blue Cross for
these services will be denied indicating that claims for these
services should be sent to DHS for consideration.
Claims Not Related to Terminal Diagnosis
Claims that are not related to a terminal diagnosis may be denied
by RHHI. These claims should then be submitted with a copy of
the Medicare denial to Blue Cross for processing. These services
can often be identified by procedure code modifier GW on
professional claims (837-P), or condition code 07 on institutional
claims (837-I).
Notification of Hospice Election
Blue Cross requires hospice providers to notify Blue Cross when a
member has elected the hospice benefit. For SecureBlue and
CareBlue members, the hospice agency should communicate the
hospice election to senior public programs unit at (651) 662-5540
or toll free at 1-800-711-9868.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (07/12/12)
11-19

Chapter 11
Coding Policies and Guidelines
(Hospital / SNF Care)
Table of Contents
Initial Hospital Care............................................................................................................. 11-2
Subsequent Hospital Visits .................................................................................................. 11-2
Critical Care.........................................................................................................................11-2
Hospital Observation Services............................................................................................. 11-3
Observation Care Discharge Day Management...................................................................11-3
Hospital Discharge............................................................................................................... 11-3
Continuing Intensive Care Services..................................................................................... 11-3
Swing Beds ..........................................................................................................................11-3
Skilled Nursing Facility Care ..............................................................................................11-4
SNF Billing for Blue Plus Government Program Products .................................................11-4
Medical Necessity Vendor...................................................................................................11-8
Leave of Absence (LOA) or Furlough Days........................................................................11-9
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12) 11-1

Coding Policies and Guidelines (Hospital / SNF Care)
Initial Hospital Care Blue Cross patients have coverage for a physician’s daily inpatient
care. Submit a separate charge for medical care on the admission
day, using codes 99221-99223. Always submit this charge as one
unit of service.
Subsequent
Hospital Visits
Bill all other inpatient visits as subsequent care, using codes
99231-99233. If the patient is still hospitalized when you bill, use
the last visit as the discharge date on the claim.
Subsequent visits may be combined on one line if all services,
diagnoses, and charges are identical, provided by the same
individual provider and the dates of service are sequential. Each
visit counts as one unit of service. The place-of-service code is
inpatient hospital (21).
Critical Care Coding of Critical Care is based first on the age of the patient.
11-2
Neonates - birth through the 28 th postnatal day would utilize
99468 and 99469. These are inpatient per day codes.
Pediatrics - 29 days old through 24 months would utilize
99471 and 99472. These are inpatient per day codes.
Pediatrics - 2 through 5 years of age would utilize 99475 and
99476. These are inpatient per day codes.
Over 71 months of age - anyone older than 71 months would
utilize 99291 and 99292. These are time-based codes.
Use code 99291 for up to and including 74 minutes of critical care.
Submit one unit of service for this code. Time duration beyond 74
minutes should be coded as 99292 with the appropriate number of
units. The narrative for 99292 states “each additional 30 minutes.”
For procedures that include time increments, over 50 percent of the
indicated time must be rendered and documented in order to bill
for the code and any additional unit(s). If code 99292 is reported it
must always be submitted with 99291.
Example:
Critical care for a 26-year-old of 2 hours’ duration.
Code Units of Service
99291 1
99292 1
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)

Hospital Observation
Services
Observation Care
Discharge Day
Management
Coding Policies and Guidelines (Hospital / SNF Care)
Blue Cross considers hospital stays for 24 hours or more as
inpatient. The hospital observation codes 99218-99220 should not
be submitted if the hospital stay is more than 24 hours.
Subsequent observation is reported under codes 99224-99226.
Evaluation and management services on the same date provided in
sites that are related to initiating “observation status” should NOT
be reported separately.
Subsequent visits provided to patients who have been admitted to
the hospital for 24 hours or more should be submitted with codes
99231-99233.
Observation or inpatient care services provided to patients
admitted and discharged on the same date of service are reported
using codes 99234-99236. The place of service can be either
inpatient or outpatient.
The discharge management code 99217 may be submitted for the
day following initial observation care when a physician performs a
final exam, discusses the observation period, provides instructions
for continued care and prepares the discharge record.
Hospital Discharge Hospital discharge day management services, 99238 or 99239, are
billable only by the provider who actually discharged the patient
on the actual date of discharge. Face-to-face contact is required on
the day of discharge.
Continuing Intensive
Care Services
Discharge summaries prepared before the patient is discharged are
not billable.
The codes 99478-99480 are used to report services subsequent to
the day of admission provided by a physician directing the
continuing intensive care of the low birth weight (LBW), very low
birth weight (VLBW) infant, or normal weight newborn who no
longer meets the definition of critically ill but continues to require
intensive observation, frequent interventions and other intensive
services. These codes are global 24-hour codes and not reported as
hourly services.
Swing Beds If the hospital census reports the patient as inpatient, use inpatient
E/M codes with an inpatient place of service. If the patient has
been discharged from inpatient status, use the skilled nursing place
of service and the corresponding E/M codes 99304-99310.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)
11-3

Coding Policies and Guidelines (Hospital / SNF Care)
Skilled Nursing Facility
Care
SNF Billing for Blue
Plus Government
Program Products
11-4
Follow the same guidelines for skilled nursing facility care as for
in-hospital medical care above. Use codes 99304-99306 for
medical care on the day of admission to a skilled nursing facility.
For follow-up care, use codes 99307-99310. The place-of-service
code is 31. Claims for skilled nursing care require admit and
discharge dates.
Discharge day management codes 99315 or 99316 are used to
report the total duration of time spent by a physician for the final
nursing facility discharge of a patient.
How to submit the Medicare Assessment line:
Loop and Segment
on 837
Description of Data Content
Loop 2400, SV201 Revenue Code for SNF PPS, example
“0022.”
Loop 2400, SV202 Three (3) character RUG code with two (2)
character assessment type indicator.
Total of five (5) characters; for example
“RVX01.”
Loop 2400, DTP03 The service date of the assessment. Service
date must fall within statement covered
period.
Loop 2400, SV205 The number of days that apply to the RUG
code in FL 44.
Loop 2400, SV203 Zero-fill this form locator; for example “0 |
00.”
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)

SNF Billing for Blue
Plus Government
Program Products
(continued)
How to bill the room & board line:
Loop and Segment
on 837I
Coding Policies and Guidelines (Hospital / SNF Care)
Description of Data Content
Loop 2400, SV201 Revenue Code for room & board; for
example “0120.”
Loop 2400, SV202 The rate charged per day for the room and
board, for example “174.41.”
Loop 2400, DTP03 Can be left blank.
Loop 2400, SV205 The number of days that room and board
were provided.
Loop 2400, SV203 The total charge for the room and board.
Skilled Nursing Facility Services should be billed with claim
facility type of bill code 02XX.
Intensive Service Days (ISD)
Nursing facility providers should bill Intensive Service Days (ISD)
with revenue code 0230.
Providers may request prior authorization and, if approved, receive
reimbursement for Intensive Service Days for a resident who is in
skilled or custodial care. ISDs can be considered regardless of
whether Blue Plus or the Department of Human Services (DHS) is
responsible for the payment of the custodial stay.
If DHS is responsible for the custodial room and board, the
nursing facility should prior authorize the ISD and then bill to
Blue Plus only the revenue code 0230 for the ISD services
provided.
If Blue Plus is responsible for the custodial room and board, the
nursing facility should prior authorize the ISD and then bill the
revenue code 0230 for the ISD services along with normal billing
procedures for the custodial room and board.
Medicaid
Custodial days are billed at the Medicaid Case Mix rate as
determined by the MN Department of Human Services.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)
11-5

Coding Policies and Guidelines (Hospital / SNF Care)
SNF Billing for Blue
Plus Government
Program Products
(continued)
11-6
How to report the Medicaid Custodial days line
Loop and Segment
on 837I
Description of Data Content
Loop 2400, SV201 Revenue Code for Medicaid Custodial
days; for example “0100” or “0101.”
Loop 2400, SV202 The rate charged per day for the Medicaid
Custodial days; for example “174.41.”
Loop 2400, DTP03 Can be left blank.
Loop 2400, SV205 The number of Medicaid Custodial days
provided.
Loop 2400, SV203 The total charge for the Medicaid Custodial
days.
Bedhold Days for Medicaid subscribers
Loop and Segment
on 837I
Description of Data Content
Loop 2400, SV201 Revenue Code for Bedhold days; for
example “0185.”
Loop 2400, SV202 The rate charged per day for the Bedhold
day.
Loop 2400, DTP03 Can be left blank.
Loop 2400, SV205 The number of Bedhold days provided and
approved.
Loop 2400, SV203 The total charge for the Bedhold days.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)

SNF Billing for Blue
Plus Government
Program Products
(continued)
Billing for Swing Beds
Coding Policies and Guidelines (Hospital / SNF Care)
The appropriate type of bill for swing bed services is 028X.
Use the correct Blue Cross provider number or NPI
specifically for billing Swing Beds (xxExx.)
Common send back issues
Loop and Segment
on 837I
Description of Data Content
Loop 2300, CLM05 Appropriate type of bill entered. TOB
should be four digits.
Loop 2010CA,
DMG02
Date of birth must be in MMDDCCYY
format.
Loop 2300, DTP03 There must be an admit date.
The admit date cannot be prior to 010102.
(Jan. 1, 2002) (If it is, change to 010102.)
Loop 2400, SV201 Use Revenue Code 0022 to report RUG
Code and Assessment Date. Use Revenue
Code 0230 for ISD days.
Loop 2400, SV202 Only use Rates on room and board lines.
RUG codes must be five (5) characters.
(Include assessment type indicator.)
Can only be submitted with five (5)
character HCPCS and up to four (4)
modifiers.
Loop 2400, DTP03 Service date must fall within statement
covers period.
Loop 2400, SV205 Do not use decimals to report units. (Round
up to the nearest whole number.)
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)
11-7

Coding Policies and Guidelines (Hospital / SNF Care)
SNF Billing for Blue
Plus Government
Program Products
(continued)
Medical Necessity
Vendor
11-8
Tips for Billing
If the stay includes a change in level of care, then additional
lines can be added onto the claim as instructed above. Indicate
the number of days associated with each level of care that is
being billed.
Skilled days and nonskilled days should be billed on separate
claims.
Part B eligible services should be billed on a separate form.
Nursing Home Communication Form
A Nursing Home Communication Form is required.
PMAP communication form process remains unchanged
The current requirement for Blue Advantage (PMAP) subscribers
and SCHA (PMAP) products will remain in place. The PMAP
Communication Form must be faxed to (651) 662-6054 before
claims are submitted.
Blue Cross, Commercial Blue Plus and BlueLink TPA have an
agreement with McKesson Health Solutions, who provides
medical necessity criteria for the majority of hospitals and health
care systems in Minnesota, for use of their InterQual Medical
Necessity Criteria.
Effective March 26, 2012, clinicians, peer reviewers and appeals
reviewers will utilize this tool to determine medical necessity and
level of care review for inpatient, long-term acute care, and acute
rehabilitation admissions and length of stay. Criteria are available
for review, on a case-by-case basis, upon request. The Blue Cross
clinician who is communicating the results of the case review will
be able to assist you with your questions.
We will extend the use of the McKesson InterQual criteria to
behavioral health and chemical dependency, along with
chiropractic, physical therapy, occupational therapy, speech
therapy, home health care and skilled nursing facility reviews on
April 1, 2012.
Government Programs will also be using McKesson InterQual
Criteria, in addition to Medicare and MHCP guidelines, for
inpatient care, long-term acute care, acute rehabilitation care and
behavioral health services.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)

Leave of Absence
(LOA) or Furlough
Days
Coding Policies and Guidelines (Hospital / SNF Care)
Blue Cross does not pay for Leave of Absence (LOA) or furlough
days as these are considered a charge or fee to “hold” a bed. Actual
services are not being provided to the patient.
Leave of absence (LOA) or furlough days are “time away” dates
during which a patient is discharged from but remains a patient of
an inpatient hospital, residential treatment program, or Skilled
Nursing Facility. If the member or patient has progressed to the
point of being able to be away from the facility, or is expected for
follow-up care or surgery and the patient does not require a
hospital level of care during the interim period, an LOA or
furlough may be granted.
Leave days may be eligible for MA payment for patients of skilled
nursing facility, nursing facility, or boarding care homes. A leave
day must be for hospital leave or therapeutic leave of a recipient
who has not been discharged from a nursing facility. A reserved
bed must be held for a recipient on hospital leave or therapeutic
leave. Payment for leave days in an SNF or NF is limited to 60%
of the applicable payment rate.
The Leave of Absence accommodation revenue codes 018X are
billed to indicate the days that the patient was not in the facility.
These codes indicate routine service charges including zero
charges for holding a room while the patient is temporarily away
from the provider. Use of this revenue code also requires that
occurrence span code 74 Noncovered level of care/LOA, and
date(s) of the absence.
Leave of Absence 018X revenue codes
0180 – Leave of Absence—General
0182 – Leave of Absence—Patient Convenience
0183 – Leave of Absence—Therapeutic Leave
0185 – Leave of Absence—Nursing Home (for Hospitalization)
0189 – Leave of Absence—Other LOA
Occurrence Span Code 74 – Noncovered Level of Care/Leave of
Absence Dates
This code and corresponding dates indicate the from and through
dates of a period of noncovered level of care or leave of absence in
an otherwise covered stay
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)
11-9

Chapter 11
Coding Policies and Guidelines
(Laboratory)
Table of Contents
Introduction..........................................................................................................................11-2
Organ or Disease-Oriented Panels.......................................................................................11-2
Lyme Disease Titer.............................................................................................................. 11-2
Office Visits.........................................................................................................................11-2
Standing Orders ................................................................................................................... 11-3
Venipunctures and Lab Handling ........................................................................................ 11-3
Collection and handling of specimens for Minnesota Health Care Program Subscribers
only .................................................................................................................................... 11-4
Papanicolaou Smears ........................................................................................................... 11-4
Pregnancy Tests ................................................................................................................... 11-6
Purchased Services/ Outside Lab......................................................................................... 11-6
Stat Lab Charges.................................................................................................................. 11-7
Repeat Lab Services............................................................................................................. 11-7
Genetic Testing Modifiers ...................................................................................................11-7
Lab Billed through the BlueCard® Program .......................................................................11-7
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (03/23/12) 11-1

Coding Policies and Guidelines (Laboratory)
Introduction Blue Cross and Blue Shield of Minnesota (Blue Cross) does not
allow providers to bill the health plan for laboratory services or
imaging studies that are not ordered by a physician or other
qualified practitioner because in addition to receiving lab or
radiology results, the patient also needs interpretation of the tests,
recommendations for future care, and a course of action that only a
physician or other qualified practitioner can deliver. In addition,
tests must be medically necessary in order to be eligible for
coverage. As a result, we will only issue payment for services that
are coordinated by a physician or other qualified practitioner. A
qualified practitioner is a practitioner recognized as an eligible
provider by Blue Cross and practices within the scope of his or her
licensure. Specific licensing questions should be directed to your
specialty’s licensing board.
Organ or Disease-
Oriented Panels
Laboratory and pathology procedures should be submitted using
the HCPCS level I or II code that best describes the service. CPT
codes 80047-89358 encompass level I codes for the majority of
laboratory and pathology procedures.
The services listed in the pathology and laboratory section of the
CPT manual may be provided by the pathologist or alternatively
by technologists who are under the supervision of the pathologist
or practitioner.
The guidelines outlined below should be adhered to when
submitting laboratory services to Blue Cross.
The tests listed under each panel (80047-80076) identify the
defined components of that panel, and all tests listed must be
performed in order to bill for that panel. Tests performed in
addition to those specifically indicated for a particular panel can be
billed separately in addition to the panel code.
Lab panels should be reported as 1 line item with 1 unit per panel.
Lyme Disease Titer Laboratory testing codes for Lyme disease titer are 86617 or
86618.
Office Visits A level-of-service office visit may be submitted in addition to
laboratory tests only when additional separately identifiable
services are provided. Obtaining a specimen for a streptococcus
test, for example, and relaying the results to the patient are
included in the reimbursement for the test itself and may not be
billed separately. A minimal level of service may be submitted if a
brief history and examination is performed in addition to the
laboratory test.
11-2
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (03/23/12)

Coding Policies and Guidelines (Laboratory)
Standing Orders Generally, laboratory tests performed because of standing orders
on file for certain patients are not covered. One example of this is a
standing order for routine screening tests when the patient has no
clinical symptoms or is not taking medications. Laboratory
services based on standing orders are covered only if you can show
the medical necessity of the services through your medical records
or if the patient has routine screening benefits and the tests are
coded with an ICD-9-CM as routine services.
Venipunctures and Lab
Handling
The following codes apply to venipunctures and lab handling:
Code Description
36415 Collection of venous blood by venipuncture
36416 Collection of capillary blood specimen (e.g., finger,
heel, ear stick)
99000 Handling and/or conveyance of specimen for transfer
from the physician’s office to a laboratory
Code 36415 is submitted when the provider performs a
venipuncture service to collect a blood specimen(s).
As opposed to a venipuncture, a finger/heel/ear stick (36416) is
performed in order to obtain a small amount of blood for a
laboratory test.
These codes should be billed only once regardless of the number
of tests performed from that specimen.
Code 99000 is an adjunct code submitted to indicate handling
and/or conveyance of a specimen for transfer from the physician’s
office to a laboratory. This code is never used for lab services
performed completely within the physician’s office.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (03/23/12)
11-3

Coding Policies and Guidelines (Laboratory)
Venipunctures and Lab
Handling (continued)
Collection and
handling of specimens
for Minnesota Health
Care Program
Subscribers only
If the lab is picking up the specimen, there is no handling cost
incurred and the clinic should not bill 99000.
The test that is being done from the specimen must be indicated on
the claim. This can be indicated by submission of the lab test code
with the -90 modifier (if you are billing for the test) or narrative
indicating the test code and/or name (done if lab will bill for test
instead of clinic). If this information is not present on the claim,
the charge will be denied if billed in addition to a venipuncture
code 36415.
For lab tests requiring routine venipuncture and subsequently sent
to an outside lab, the physician office may bill either the
venipuncture service or the handling charge, but not both
(i.e., 36415 or 99000).
Due to a benefit change dictated by the Minnesota Department of
Human Services effective for dates of service February 3, 2012
and after Blue Plus will no longer reimburse for the collection of
blood by venipuncture (CPT 36416), capillary (CPT 36415) or
access port (CPT 36591 and 36592) in conjunction with another
service for Minnesota Health Care Programs Subscribers. These
services (36415, 36416, 36591 and 36592) will be denied as
incidental, or included in a primary service when billed in
conjunction with another service.
Papanicolaou Smears The procedure codes, diagnosis codes, specimen collection codes
and handling fee that apply to Papanicolaou smears are detailed
below.
11-4
Procedure Codes
Codes 88142-88154, 88164-88167, 88174-88175, P3000, P3001,
G0123-G0124, and G0141, G0143-G0148 are for cytopathology
screening of cervical or vaginal smears. Submit the appropriate
code to reflect the service provided.
Procedure code 88141 and 88155 are used to report physician
interpretation of a cervical or vaginal specimen and should be
listed in addition to the screening code chosen when the additional
services are provided.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (03/23/12)

Papanicolaou Smears
(continued)
Diagnosis Codes
Coding Policies and Guidelines (Laboratory)
Routine cervical Papanicolaou smears should be reported with
appropriate ICD-9-CM diagnosis codes:
Use this code… In this situation…
V72.32 As part of a general gynecological examination
V76.2 Without a general gynecological examination
Pap smears performed due to illness, specific related symptoms,
or relevant personal or family history should be reported with the
most specific ICD-9-CM code available.
Specimen Collection Codes
The specimen collection code for a Pap smear (Q0091) is not
separately reimbursable. Specimen collection is included in the
level of service reported for the examination and evaluation and
should not be billed separately. The collection code will be denied
as incidental regardless of what, if any, other service is billed with
the code.
Handling Fee
Code 99000 may be submitted for the cost incurred by the clinic
for the handling and/or conveyance of the Pap smear for transfer
from the physician’s office to an outside laboratory. This code is
never submitted for cytopathology screening performed within the
physician’s office.
Modifier -90 (reference outside laboratory) must also be submitted
when the screening is performed by a party other than the treating
or reporting physician. This modifier would be submitted with the
Pap smear code (e.g., 88150-90). Narrative indicating the test
being done may be submitted in lieu of the procedure code and
modifier if the lab will be billing Blue Cross for the test instead of
the clinic.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (03/23/12)
11-5

Coding Policies and Guidelines (Laboratory)
Pregnancy Tests Pregnancy tests should be coded as follows:
Purchased Services/
Outside Lab
11-6
Code Description
84702 Quantitative, serum
84703 Qualitative, serum
81025 Urine
Laboratory records must document the method (quantitative or
qualitative) of testing done and the type of specimen used (serum
or urine).
The entity that performs a test should be the one to bill for that
test. However, a provider may, under arrangement with another
provider, bill a service that is purchased from that other provider.
For example, a clinic may bill for a Pap smear that is sent to an
independent lab for analysis, or for an X-ray that is done at a
hospital because the clinic did not have the appropriate equipment.
It is important to remember that only one provider may bill for the
service.
Claims for purchased services should be submitted on the 837P
format as follows:
Loop 2300, CLM05-1 (place of service) - enter the place of
service code where the service was done by the performing
provider.
Loop 2400, SV101-2 (procedure/modifier) - enter the
procedure code of the test and the modifier 90.
Loop 2400, SV101-1 (ID qual) - enter the two-character
qualifier in the shaded area if there is an ID submitted in 24J
shaded.
Loop 2310B, NM109 or REF02 (rendering provider ID) -
enter the NPI provider number of the ordering physician or the
legacy ID if the provider was not NPI eligible.
Loop 2310D (service facility location information) - enter the
name and address of the performing provider.
Loop 2310D, NM109 (NPI #) or REF02 (service facility
provider) - enter the NPI provider number of the service
facility location or the legacy ID if the provider was not NPI
eligible.
Loop 2010AA, NM109 (NPI) or REF02 (billing provider) -
Enter the NPI provider number of the billing provider or the
legacy ID if the provider was not NPI eligible.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (03/23/12)

Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (03/23/12)
Coding Policies and Guidelines (Laboratory)
Stat Lab Charges Charges for stat laboratory requests (S3600 and S3601) are not
allowed. If submitted, they will deny as provider liability.
Repeat Lab Services Repeat services require modifier 91 (not 59), unless the narrative
supports submission of multiple units.
Genetic Testing
Modifiers
Lab Billed through the
BlueCard® Program
Genetic coding modifiers (0A-9Z) are developed and maintained
by the AMA. These modifiers are required when reporting a
genetic lab procedure, as appropriate.
Blue plans* may contract with providers outside of their exclusive
service area for services provided to local and BlueCard members
within their own service area for independent clinical lab services.
Blue plans may not contract for such services for their members
who receive services outside of their service area.
Lab
Providers who perform lab services should file the claim to the
Blue plan in whose service area the specimen was drawn. The
claim will be reimbursed based on provider’s participation status
with that Blue plan.
* Each Blue plan is an independent licensee of the Blue Cross and
Blue Shield Association
11-7

Chapter 11
Coding Policies and Guidelines
(Maternity)
Table of Contents
Global Obstetrical Care........................................................................................................ 11-2
Antepartum Care.................................................................................................................. 11-2
Delivery................................................................................................................................ 11-2
Subsequent VBACs .............................................................................................................11-2
Postpartum Care................................................................................................................... 11-2
Initial Visit and Itemized Services.......................................................................................11-2
Submission Options and Coding Alternatives .....................................................................11-3
Pre-term Birth Prevention Services ..................................................................................... 11-4
Two Physicians Involved in Care/ Same Tax ID.................................................................11-5
Newborn Care ...................................................................................................................... 11-5
Complications or Unusual Circumstances...........................................................................11-6
Exceptions............................................................................................................................11-6
Lactation Education ............................................................................................................. 11-6
Collection of Umbilical Cord Blood.................................................................................... 11-6
Obstetrical Care Coding Alternatives ..................................................................................11-7
Reproduction Treatment ...................................................................................................... 11-8
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12) 11-1

Coding Policies and Guidelines (Maternity)
Global Obstetrical Care Blue Cross and Blue Shield of Minnesota (Blue Cross) accepts the
global obstetric care codes 59400, 59510, 59610 and 59618, which
include antepartum care, delivery, and postpartum care.
Antepartum Care Antepartum care includes the subsequent history and physical
examinations, recording of weight, height, blood pressures, fetal
heart tones, chemical urinalysis, maternity counseling, and
monthly visits up to 28 weeks gestation, biweekly visits to 36
weeks gestation, and weekly visits until delivery. Any other visits
or services within this time period should be coded separately.
The provider may choose to bill globally, visit-by-visit, or to use
codes 59425 or 59426 for antepartum care. The date of service
submitted for antepartum care should be the date of delivery.
If antepartum care is not performed for the entire period, code each
E/M service separately.
Delivery Delivery includes admission history and physical, management of
uncomplicated labor, and delivery (with or without episiotomy or
forceps). Vaginal delivery only should be submitted with
procedure code 59409 or 59612 (VBAC).
Cesarean (C-section) delivery only should be submitted with code
59514 or 59620 (VBAC).
Only one delivery code should be billed regardless of the number
of births during that delivery.
Subsequent VBACs Vaginal births after a C-section (VBACs) should be coded using
CPT codes 59618, 59620, 59622 regardless if the vaginal birth is
the first or subsequent following the C-section.
Postpartum Care Postpartum care includes hospital visits and one to two office visits
for usual, uncomplicated postpartum follow-up, urinalysis, and
hemoglobins. The global codes (59400, 59510, 59610, or 59618)
and delivery codes (59410, 59515, 59614, or 59622) include
postpartum care.
Initial Visit and
Itemized Services
11-2
Submit the postpartum care package (separate procedure) code
59430 only when another provider does the delivery. Submit this
code one time with one unit of service. The date of service should
be the delivery date.
The initial visit may be billed separately with an appropriate E/M
code. An obstetrical profile (80055) and any laboratory procedure
codes (other than urinalysis) should also be submitted separately.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)

Submission Options
and Coding
Alternatives
The following submission options are available:
Coding Policies and Guidelines (Maternity)
The global codes 59400, 59510, 59610, and 59618 may be
submitted with one charge. For contracts subject to Minnesota
legislative mandated benefits and others that waive
deductibles, copays, or coinsurance on antepartum care, Blue
Cross will process these services separately from the delivery
and postpartum care. The global maternity charge will be split
based on RBRVS (Resource Based Relative Value System)
work values. The provider Remittance Advice will report
procedure code 59426 with a payment at 100 percent of the
allowance and a delivery code 59410, 59515, 59614, or 59622
with a payment determined according to the contract’s
benefits.
For contracts that are not subject to Minnesota legislative
mandated benefits and/or where antepartum care is subject to
regular contract benefits, the global codes 59400, 59510,
59610 and 59618 will process with the charge and code as
submitted.
Providers may submit the appropriate E/M codes for each
antepartum visit individually with the delivery code 59410,
59515, 59614, or 59622 as an alternative to submitting the
global maternity codes 59400, 59510, 59610, or 59618.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)
11-3

Coding Policies and Guidelines (Maternity)
Pre-term Birth
Prevention Services
11-4
Blue Cross will reimburse for certain pre-term birth prevention
services when the patient’s contract covers these services.
Code Narrative Billing
H1000 Prenatal Care, at-risk assessment
[use the Minnesota Pregnancy
Assessment Form, DHS 3294 (1/97)
to complete assessment or the
American College of Obstetrics and
Gynecology (ACOG) pregnancy
assessment form]
H1001 Prenatal care, at-risk enhanced
service; antepartum management
H1003 Prenatal care, at-risk enhanced
services; education
Done twice for
all patients; once
at initial OB visit
and once at 24-
28 weeks.
If the patient is
identified via the
assessment as
high risk. This
code may be
billed once.
If the patient is
identified via the
assessment as
high risk. This
code may be
billed once.
The services represented by the prenatal care at-risk codes H1002,
H1004 and H1005 are already included in the provider’s normal
prenatal care and not separately reimbursed.
Please refer to Chapter 4 Case Management for information on
the Minnesota Pregnancy Assessment Form.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)

Two Physicians
Involved in Care/
Same Tax ID
Coding Policies and Guidelines (Maternity)
There are situations where the primary physician provides prenatal
and postnatal care but does not deliver the baby. The most
common situation noted is when a surgeon from the same medical
group as the primary physician delivers the baby via C-section.
Many times the primary physician is also acting as an assistant-atsurgery.
In the case where both physicians are in the same practice
(same tax ID), Blue Cross is recommending the following
submission guides:
Same tax-ID – clinic provider number reported for the claim
Surgeon – bills the global C-section (59510); individual
provider number or NPI of the surgeon reported on the service
line
Primary physician – bills the C-section assist (59514-80);
individual provider number or NPI of the physician reported on
the service line
Provider production and disbursement of reimbursement is an
internal process. It is the clinic’s responsibility to assure the
providers participating in the patient’s care are appropriately paid.
Newborn Care Submit procedure code 99460 or 99462 and diagnosis code V20.1
to bill for routine services in the hospital for well newborns. If the
newborn is ill, submit codes 99221-99223 or 99231--99233 for
hospital visits. Initial hospital care of neonates, 28 days of age or
less, who require intensive observation, frequent interventions, and
other intensive care services is reported with code 99477.
Subsequent intensive care for very low birth weight infants is
reported with codes 99478-99480, depending on the weight of the
infant. For discharge day management, submit 99238. Pediatric
standby should be submitted with code 99464. Standby services
are requested by another physician. The physician may not be
providing care or services to other patients during this period.
Standby, 99464, includes the initial stabilization of the newborn,
thus services may be denied as incidental to 99464. When billing a
newborn circumcision (54150 or 54160) on the day of discharge,
add modifier –25 to code 99238. A diagnosis indicating the
circumcision (V50.2) must be linked as the primary diagnosis to
the circumcision procedure (54150 or 54160).
For neonatal critical care services see codes 99468-99476.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)
11-5

Coding Policies and Guidelines (Maternity)
Complications or
Unusual Circumstances
Submit modifier –22 with specific documentation to justify
additional reimbursement along with the delivery or operative
report for complications during delivery. Unusual circumstances
resulting in extensive antepartum or postpartum care should be
coded separately. A narrative/operative report should be sent with
the claim.
Exceptions These guidelines apply to the majority of contracts. Exceptions
include, but are not limited to, the Federal Employee Plan (FEP)
and 3M.
The Federal Employee Program contract does not allow
payment for individual visits prior to delivery. Those services
will be rejected. Antepartum care should be submitted as part
of the global maternity code after delivery.
For 3M contracts and others that require a copayment per visit,
Blue Cross will request the number of antepartum visits if the
global maternity codes 59400, 59510, 59610, or 59618 or the
antepartum codes 59425 or 59426 are submitted.
Lactation Education If done as part of the delivery, lactation education should be billed
on the 837I, on the mother’s claim. If this is done after discharge,
it should be incorporated into the E/M for postpartum care.
Collection of Umbilical
Cord Blood
11-6
Collection of umbilical cord blood may be done at the time of a
delivery either for donation to organizations such as the Red Cross
or per the patient’s request to bank the blood for possible future
need. Regardless of intent, cord blood collection is not a
reimbursable service. If billing for the collection per the request of
the patient, the patient must be notified that this charge will be
their liability. The charge should be submitted using an unlisted
procedure code, such as 59899, with a narrative description and
will be denied as subscriber liability.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)

Obstetrical Care
Coding Alternatives
Coding Policies and Guidelines (Maternity)
Different options are available for billing Obstetrical care. Listed
below are some of the variations. Generally, global billing is
preferred.
Global Billing
Global Billing includes the antepartum care, delivery, and postpartum
care.
59400 Vaginal delivery
59510 C-section
59610 VBAC
59618 C-section after VBAC
Antepartum Care Only
59425 4 – 6 Visits
59426 7 Visits
E/M Evaluation and Management codes billed for each
visit.
Delivery Only
59409 Vaginal delivery
59514 C-section
59612 VBAC
59620 C-section after VBAC
Delivery and Post-partum Only
59410 Vaginal delivery
59515 C-section
59614 VBAC
59622 C-section after VBAC
Post-partum Care Only
59430
E/M Evaluation and Management codes billed for each
visit
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)
11-7

Coding Policies and Guidelines (Maternity)
Reproduction
Treatment
11-8
All Blue Cross and Blue Plus large group fully insured and Service
Cooperative plans include a Reproduction Treatment combined
lifetime dollar maximum benefit.
Medical policy
For medical policy information, including medical codes defining
treatment, refer to the reproduction treatment medical policy, II-
02, found on the Blue Cross website.
Reproduction treatment services
Artificial insemination (AI): The introduction of semen from a
donor into a woman’s vagina, cervical canal or uterus by
means other than sexual intercourse.
Intrauterine insemination (IUI): A specific method of artificial
insemination in which semen is introduced directly into the
uterus.
Non-investigative assisted reproductive technologies (ART):
Fertility treatments in which both eggs and sperm are handled.
ART procedures involve surgically removing eggs from a
woman’s ovaries, combining them with sperm in the laboratory
and returning them to the woman’s body or donating them to
another woman.
Non-investigative drugs used to treat anovulation, ovarian
dysfunction or unexplained infertility in women. Reproduction
Treatment drugs include, but are not limited to:
Ovulatory stimulants, including follitropins and
monotropins
Chorionic gonadotropin (HCG)
Gonadotropin-releasing hormones
Ineligible services include, but are not limited to:
cryopreservation of reproductive tissue, embryos, or sperm
thawing of cryopreserved reproductive tissue, embryos, or
sperm
management and/or storage of reproductive tissue, embryos, or
sperm
donor services relating to reproductive tissue, embryos, or
sperm
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)

Reproduction
Treatment (continued)
Benefit information
Coding Policies and Guidelines (Maternity)
Services defined by Blue Cross and Blue Plus as reproduction
treatment are subject to a combined lifetime dollar maximum per
person for all eligible medical and prescription drug services.
Charges related to reproduction treatment will be combined for all
networks. Services related to infertility testing will continue to
process under “physician services” and will not be subject to the
lifetime dollar maximum for reproduction treatment.
The dollar maximum is a combination of the following services:
Artificial insemination (AI)
Intrauterine insemination (IUI)
Non-investigative assisted reproductive technologies (ART)
Associated lab and diagnostic imaging services
Prescription drugs, which include injections either selfadministered
or administered by a health care professional and
oral prescription drugs
Coverage of medications is subject to a product-specific
formulary, specialty drug program or other requirements as
outlined within a subscriber’s specific contract benefits.
Prior authorization is only required for benefit plans without dollar
maximum limitations.
Definitions
Infertility testing: Services associated with establishing the
underlying medical condition or cause of infertility. This may
include the evaluation of female factors (e.g., ovulatory, tubal
or uterine function), male factors (e.g., semen analysis or
urological testing) or a combination of both. Infertility testing
involves a physical examination, laboratory studies and
diagnostic testing performed solely to rule out causes of
infertility or establish an infertility diagnosis.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)
11-9

Coding Policies and Guidelines (Maternity)
Reproduction
Treatment (continued)
11-10
Reproduction treatment: Treatment to enhance the reproductive
ability among subscribers experiencing infertility after a
confirmed diagnosis of infertility has been established due to
either female, male factors or unknown causes. Treatment may
involve oral and/or injectable medication, surgery, artificial
insemination, intrauterine insemination, assisted reproductive
technologies or a combination of these.
Six-cycle: A cycle is defined as one partial or complete
fertilization attempt extending through the implantation phase
only. A treatment cycle can involve both drugs and
insemination and can be timed with the completed menses.
Once a pregnancy is confirmed, the cycles can begin again.
Any cycle billed to the claims administrator using artificial
insemination (AI), intrauterine insemination (IUI) and/or
prescription drugs will be applied to the six-cycle maximum. If
the patient abandons a treatment regimen before the cycle is
complete, the partial cycle may be counted as one of the six (6)
eligible cycles or the patient may assume all charges for that
cycle in order to preserve benefits for six (6) complete cycles.
Note: Some self-insured plans may still elect this benefit
instead of a dollar maximum.
Disclaimer
The defined reproduction treatment services and related coding
applies to all Blue Cross and Blue Plus large group fully insured
and Service Cooperative plans. Minnesota Health Care Programs,
including Prepaid Medical Assistance (PMAP), MinnesotaCare
(MNCare), and General Assistance Medical Care (GAMC),
exclude benefits for reproduction or infertility treatment. Benefits
for self-insured plans may vary. This benefit does not apply to
Blue Cross Medicare products. Please contact provider services for
additional benefit information. Coverage decisions are subject to
all terms and conditions of the applicable benefit plan, including
specific exclusions and limitations, and to applicable state and/or
federal law.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)

Chapter 11
Coding Policies and Guidelines
(Medical Emergency)
Table of Contents
Introduction..........................................................................................................................11-2
Criteria for Medical Emergencies........................................................................................ 11-2
Emergency Department Services......................................................................................... 11-3
Extended/After-hours Clinics ..............................................................................................11-4
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (03/23/12) 11-1

Coding Policies and Guidelines (Medical Emergency)
Introduction Some subscribers have full coverage for an outpatient medical
emergency, which we generally define as the sudden and
unexpected onset of a condition requiring immediate medical
attention. To receive full benefits, the subscriber must seek care
within specified time limits, usually within 24 to 72 hours of the
onset of acute symptoms. Accidental injury may not be included in
the medical emergency benefits. Many coverage plans have
separate first-aid or accident benefits.
Criteria for Medical
Emergencies
11-2
Use the guidelines below to determine if you should submit a
claim as a medical emergency. Medical emergency charges
should be submitted with the date and time the emergency
occurred. If the emergency is related to pregnancy, also indicate
that the charges were for emergency services.
Were the symptoms sudden, severe and life threatening?
Did the condition require immediate medical (not surgical)
attention?
Did the patient see a doctor no later than 72 hours after the
problem began?
Did the time or date of the visit indicate it was an emergency?
The following situations generally would not indicate a medical
emergency:
scheduled surgeries or diagnostic procedures such as colon or
IVP X-rays
follow-up visits for further injections, such as antibiotics
suture removal
urgent but non-life-threatening situations seen during regular
office hours
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (03/23/12)

Emergency
Department Services
Coding Policies and Guidelines (Medical Emergency)
Emergency department services (codes 99281-99285) are
submitted by the physician assigned to the emergency room.
Assignment is defined as a formal relationship between the
physician and the hospital whereby the physician is solely
responsible for seeing patients in the emergency room during a
specified time period.
Physicians who specialize in emergency medicine and use the
emergency department as their place of business are generally
considered assigned to the emergency room.
Other physicians who have arrangements with the hospital to be
‘‘on call’’ to see patients in the emergency department during
specific hours may also be considered assigned to the emergency
department while seeing patients there. In this case, the physician’s
primary responsibility is to the emergency department and the
arrangement is between the physician and the hospital, as opposed
to an agreement between physicians to cover one another’s
patients over the weekend, etc.
Any physician seeing a patient in the emergency department to
which he/she is not assigned must submit level-of-service office
calls according to CPT guidelines.
Emergency department visit evaluation and management codes are
restricted to the emergency place of service (23), in accordance
with CPT coding rules. Codes 99281-99285 will be denied
provider liable as incompatible if submitted with any place of
service (POS) other than 23.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (03/23/12)
11-3

Coding Policies and Guidelines (Medical Emergency)
Extended/After-hours
Clinics
11-4
Blue Cross and Blue Shield of Minnesota (Blue Cross) does not
consider an extended/after-hours clinic to be an emergency
department. An emergency department is defined as an organized
hospital-based facility for the provision of unscheduled episodic
services to patients who present for immediate medical attention.
The facility must be available 24 hours a day.
Clinic-based urgent care services may be billed under the place of
service (POS) 20. The POS code 20 will apply office benefits to
the services if submitted. DO NOT bill a corresponding facility
claim with the revenue code 0456 if already billing for urgent care
on the professional claim (837P). This would be considered
duplicate billing. Hospital-based emergency room urgent care
should be billed on the 837I only with the revenue code 0456.
Codes S9083 (global fee urgent care centers) and S9088 (services
provided in an urgent care center) represent where the service was
rendered, not the service itself. Thus, they are not separately
covered and will be denied as part of the primary service (such as
an E/M).
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (03/23/12)

Chapter 11
Coding Policies and Guidelines
(Medical Services)
Table of Contents
Evaluation and Management (E/M)..................................................................................... 11-3
Office or Other Outpatient and Initial Inpatient Consultations .........................................11-11
New and Established Patients ............................................................................................ 11-12
Preventive Medicine ..........................................................................................................11-12
Hospital Discharge.............................................................................................................11-13
Allergy Testing .................................................................................................................. 11-13
Allergy Immunotherapy.....................................................................................................11-13
Anticoagulation Clinic-S9401 ...........................................................................................11-14
Blood, Occult, Feces Screening......................................................................................... 11-14
Cardiovascular Stress Test................................................................................................ 11-14
Chemotherapy Administration........................................................................................... 11-15
Chemical Dependency Assessment ................................................................................... 11-16
CHF Telemonitoring..........................................................................................................11-16
Day Treatment ................................................................................................................... 11-19
Diabetic Education.............................................................................................................11-19
E-Care Visits......................................................................................................................11-20
Ear Wax Removal..............................................................................................................11-24
G0101.................................................................................................................................11-24
Immunizations.................................................................................................................... 11-25
Billing Options for Medicare Part D Vaccines.................................................................. 11-30
Injections............................................................................................................................11-32
Appealing Unlisted Drug Allowances ............................................................................... 11-33
Infusion Therapy................................................................................................................ 11-34
Injection and Infusion Services Restrictions......................................................................11-34
Dispensing Fees ................................................................................................................. 11-34
Interpreter Services ............................................................................................................ 11-34
Transfusion—Blood and Blood Products .......................................................................... 11-34
Locum Tenens.................................................................................................................... 11-35
Natural Family Planning.................................................................................................... 11-35
Nicotine Dependence.........................................................................................................11-35
Revenue Codes Used by Facilities 0944 or 0945 ..............................................................11-37
Eligibility to Bill for Specific Procedures/Services...........................................................11-37
Coverage for Tobacco Treatment Medications..................................................................11-38
Noncovered Tobacco Treatments ...................................................................................... 11-38
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12) 11-1

Coding Policies and Guidelines (Medical Services)
11-2
Medication Therapy Management (MTM) ....................................................................... 11-38
Oral Medication................................................................................................................. 11-40
Non-Physician Health Care Practitioners.......................................................................... 11-40
Practitioners That ARE Credentialed by Blue Cross and Issued Individual Provider
Number/NPIs..................................................................................................................... 11-41
Practitioners that are NOT Credentialed by Blue Cross But Are Issued Individual Provider
Number/NPIs..................................................................................................................... 11-42
Counseling and/or Risk Factor Reduction......................................................................... 11-42
Room or Machine Set-Up Charges.................................................................................... 11-42
Supplies in the Office ........................................................................................................ 11-42
Adjunct CPT Codes........................................................................................................... 11-42
Care Plan Oversight Services ............................................................................................ 11-42
Prolonged Physician Services............................................................................................ 11-43
Telephone Calls................................................................................................................. 11-43
Medical Team Conferences............................................................................................... 11-43
Televideo Consultations .................................................................................................... 11-43
Televideo Coverage Exceptions........................................................................................ 11-45
Unusual Travel .................................................................................................................. 11-45
Urgent Care ....................................................................................................................... 11-45
Weight Management Care................................................................................................. 11-46
Assessment Management Program for Fully Insured ....................................................... 11-51
Health Care Home (HCH)................................................................................................. 11-53
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)

Evaluation and
Management (E/M)
Coding Policies and Guidelines (Medical Services)
Evaluation and management (E/M) services refer to visits and
consultations furnished by physicians or other qualified
practitioners.
The E/M section of the CPT manual is divided into broad
categories such as office visits, hospital visits, and consultations.
Each section has basic guides or requirements for selection, such
as new versus established patient, or office versus hospital based
services.
Evaluation and Management Basics
Blue Cross and Blue Shield of Minnesota and Blue Plus (Blue
Cross) would like to clarify and expand on our requirements for
E/M services. The following guides cover how Blue Cross treats
preventive and illness E/M services and what Blue Cross expects
for documentation if the claim is appealed.
Documentation
Blue Cross requires reasonable documentation that services are
consistent with the health plan coverage provided, that services are
medically necessary, and appropriate diagnostic and/or therapeutic
services are provided and/or the services furnished have been
accurately reported. Documentation does not need to be submitted
with every claim; however, it must be readily available on request
or submitted, as appropriate, with an appeal or replacement claim.
It is important to note that even if all requirements of a code are
documented, if medical necessity is not established, the service
may be denied.
The principles of documentation listed below are applicable to all
types of medical and surgical services in all settings. For E/M
services, the nature and amount of physician work and
documentation varies by type of service, place of service and the
patient's status. The general principles listed below may be
modified to account for these variable circumstances in providing
E/M services.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)
11-3

Coding Policies and Guidelines (Medical Services)
Evaluation and
Management (E/M)
(continued)
11-4
1. The medical record should be complete and legible. Vitals,
forms, and anything pertaining to the visit needs to be
complete and contained in the record.
2. The documentation of each patient encounter should include:
reason for the encounter and relevant history, physical
examination findings and prior diagnostic test results;
assessment, clinical impression or diagnosis;
plan for care; and
date and legible identity of the observer. On review,
documentation not signed by the physician/practitioner
performing the service will subject the entire visit to denial.
3. If not documented, the rationale for ordering diagnostic and
other ancillary services should be easily inferred.
4. Past and present diagnoses should be accessible to the treating
and/or consulting physician.
5. Appropriate health risk factors should be identified.
6. The patient's progress, response to and changes in treatment,
and revision of diagnosis should be documented.
7. The CPT and ICD-9-CM codes reported on the health
insurance claim form or billing statement should be supported
by the documentation in the medical record. Include ALL
diagnoses addressed during the encounter. Diagnoses MUST
be coded to the highest degree of specificity for accurate risk
adjusted quality review.
Additional reminders:
Use of the term IBID (same as above) and/or the use of
quotation marks to replace or repeat previously documented
information is not acceptable. All information must be in datesequence
order.
Use of question marks (?) or underline (________) are not
considered to be part of a complete medical record. Dictation
transcription should be reviewed by the medical practitioner
and updated prior to sign-off to ensure complete medical
records are maintained.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)

Evaluation and
Management (E/M)
(continued)
Coding Policies and Guidelines (Medical Services)
Each page in the medical record must contain the patient’s
name and/or identification number.
All encounters/entries must be dated.
Services not clearly documented are not covered by Blue Cross
and will be denied as participating provider liability. Failing to
submit requested medical records may result in claims being
denied or payment being recouped from a provider. Patients
are not financially liable for services that are denied for
inadequate documentation.
What information would constitute as a plan of care?
For a physician’s note to qualify as a plan of care, it would need to
contain at least:
the patient’s diagnosis,
long term goals,
and the type, amount, duration and frequency of services.
It must be established before treatment has begun and may be
adjusted by the appropriate practitioner.
Time Documentation
The time spent face-to-face with either the patient or family should
be noted for every service. This is particularly important in a
situation where counseling and/or coordination of care dominates
more than 50 percent of the face-to-face physician time. In this
situation, time is considered the key or controlling factor, and the
extent of counseling and/or coordination of care must be
documented in the medical record.
Consider that in an eight or nine hour work day; there are a given
number of time units which may be allocated to E/M services.
Obviously, the collective time reported, as reflected in the choice
of E/M services codes, cannot exceed the amount of time available
in the work day.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)
11-5

Coding Policies and Guidelines (Medical Services)
Evaluation and
Management (E/M)
(continued)
11-6
1995 and 1997 E/M Guidelines
Blue Cross will accept either the Centers for Medicare and
Medicaid (CMS) 1995 or 1997 E/M documentation guidelines.
Refer to the following publications for the official documentation
guidelines:
1995 Documentation Guidelines for Evaluation and
Management Services, available at
www.cms.hhs.gov/MLNProducts/Downloads/1995dg.pdf on
the CMS website;
1997 Documentation Guidelines for Evaluation and
Management Services, available at
www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.p
df on the CMS website.
What are the differences between the 1995 and 1997 Medicare
E/M guidelines when it pertains to the different exam levels?
The 1995 Guidelines define the different exam levels as follows:
Problem Focused -- a limited examination of the affected
body area or organ system.
Expanded Problem Focused -- a limited examination of the
affected body area or organ system and other symptomatic or
related organ system(s).
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)

Evaluation and
Management (E/M)
(continued)
Coding Policies and Guidelines (Medical Services)
Detailed -- an extended examination of the affected body
area(s) and other symptomatic or related organ system(s).
Comprehensive -- a general multi-system examination or
complete examination of a single organ system.
The 1997 Guidelines contain the following definitions:
Problem Focused Examination -- should include
performance and documentation of one to five elements
identified by a bullet (o) in one or more organ system(s) or
body area(s).
Expanded Problem Focused Examination -- should include
performance and documentation of at least six elements
identified by a bullet (o) in one or more organ system(s) or
body area(s).
Detailed Examination -- should include at least six organ
systems or body areas. For each system/area selected,
performance and documentation of at least two elements
identified by a bullet (o) is expected. Alternatively, a detailed
examination may include performance and documentation of at
least twelve elements identified by a bullet (o) in two or more
organ systems or body areas.
Comprehensive Examination -- should include at least nine
organ systems or body areas. For each system/area selected, all
elements of the examination identified by a bullet (o) should be
performed, unless specific directions limit the content of the
examination. For each area/system, documentation of at least
two elements identified by a bullet is expected.
Illness E/M and Preventive on Same Date
Preventive E/M services reflect an age and gender appropriate
history/exam. The types of services will vary and include
counseling or anticipatory guidance based on age and/or sex.
For example, an E/M preventive service for a 28-year-old adult
female may include a pelvic examination including obtaining a
Pap smear, breast examination, and counseling regarding diet and
exercise, substance abuse, sexual activity, and birth control.
What is included in each?
Generally, the following distinguish an evaluation and
management illness/problem-oriented code (99201-99215) from a
preventive exam code (99381-99397)
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)
11-7

Coding Policies and Guidelines (Medical Services)
Evaluation and
Management (E/M)
(continued)
11-8
Illness/Problem-oriented Preventive
1. Management 3 Chronic
Conditions, or
2. Chief Complaint
(CC)/Problem oriented
3. History of Present Illness
(HPI)/Status of conditions
4. Review of Systems (ROS)
as applicable
5. Past, Family and Social
History (PFSH) as
applicable
6. Appropriate Exam based on
presenting problem
7. Decision
Making/Risk/Treatment
8. Diagnosis-condition, signs
or symptoms
9. Bill Level based on work
performed/risk
1. Patient asymptomatic
2. No CC or PI
3. Comprehensive ROS
4. Comp or interval PFSH
5. Comprehensive Exam
6. Risk Reduction
7. Counseling
8. Diagnosis – V Codes
9. Select Code based on age
and new or established
Immunizations and ancillary studies involving lab, X-rays or other
procedures/services are not included in either type of service and
should be reported separately using the appropriate diagnosis.
Significant and separately identifiable
In the event that a problem or abnormality requires additional work
and the performance of the key components of a problem-oriented
E/M service, modifier -25 should be appended to the
Office/Outpatient code reported. Appending modifier -25 indicates
that a significant, separately identifiable E/M (above and beyond
the preventive medicine E/M service) was provided by the same
physician on the same day as the preventive medicine service.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)

Evaluation and
Management (E/M)
(continued)
What is significant?
Coding Policies and Guidelines (Medical Services)
An issue is considered a “significant issue” when a new or
different abnormality/medical problem or a change or exacerbation
of a previous condition is revealed in the process of examining the
patient and the physician determines it is significant enough to
require additional work to perform the components of the
appropriate E/M.
What is identifiable?
Separate documentation or records are not required, but it needs to
be clear to an auditor/someone outside of the clinic what
documentation relates to the preventive E/M and what to the
illness E/M. The chief complaint for the illness E/M should be
clearly identifiable in the record. The illness complaint or
abnormal finding should not be intermixed within the body of the
physical exam documentation. Regardless of what guide used, any
part of the preventive exam cannot be used again to support the
billing of the illness E/M, such as patient history or review of
systems.
What doesn’t count for extra work for support of the illness
E/M?
Prescription refills and/or samples for chronic stable conditions
Rule out X-rays
Rule out blood work
Referral to another physician
Decision to “observe” (is not considered treatment)
Chronic or past diagnosis(es) that are not treated (for example,
change in meds)
Results of test(s)
If treated at the visit, an uncontrolled diagnosis must be supported
in the documentation in order to be considered.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)
11-9

Coding Policies and Guidelines (Medical Services)
Evaluation and
Management (E/M)
(continued)
11-10
Why does Blue Cross deny level 4 or 5 illness E/Ms with a
preventive E/M?
Codes 99214 and 99215 involve a moderate or high complexity
review and the focus of the visit may no longer be preventive in
nature. Denials may be appealed. All supporting documentation
must be included with the appeal request or will be denied for lack
of documentation. For example, if the doctor states “vitals as
noted” or “physical form filled out,” the documentation must state
where it is noted in the chart. This should be included with the
appeal.
Why doesn’t Blue Cross allow codes 99201-99205 with a
preventive E/M?
New patient illness E/M codes will not be allowed with preventive
E/M codes, including the new patient preventive E/M codes
99381-99387. The additional work for an initial service will be
met in the billing of the initial preventive E/M. Any additional
E/M service during the same would be considered established.
Although the CPT manual may not clearly state that a new illnessrelated
E/M should not be billed with a new patient preventive
exam, Blue Cross will not allow two new patient services at the
same visit based on the rationale stated above. Because the patient
already received professional services as part of the preventive
E/M, he or she no longer meets the ‘new patient’ criteria. New
patients are those who have not been seen by a member of the
group in same specialty during the prior three-year period.
When may it be appropriate to bill an office visit on the same
day as a procedure?
If the patient comes in only for the procedure – only bill for the
procedure.
If the patient comes in knowing they are going to have the
procedure done, but they also have a new complaint, then the
practitioner may code for the E/M appended with the -25 modifier
and the procedure.
If the patient comes in with a new complaint, and during that time
the practitioner makes the decision that a particular procedure
needs to be done at that visit, then the practitioner may code for the
procedure and the E/M appended with the -25 modifier.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)

Office or Other
Outpatient and Initial
Inpatient
Consultations
Coding Policies and Guidelines (Medical Services)
CMS does not allow submission of inpatient and outpatient
consultation codes for Medicare claims. This coding and
submission will be followed only for our Medicare business. There
is no change for all other lines of business. Blue Cross accepts all
valid HIPAA medical codes. The consultation codes 99241-99245
and 99251-99255 are still valid CPT codes and as such will be
accepted. We expect that the documentation will support any code
submitted.
Consultation codes 99241-99255 include a physician’s services
requested by another physician or other appropriate source, for
further evaluation or management of the patient. They are
designated according to place of service and apply to new or
established patients.
The consultant must document the consult request and the reason
for the consult in the patient record and must also appear in the
requesting practitioner’s plan of care.
The consult request is typically in writing but it may be verbal so
long as both the requestor and the consultant document the
conversation in the patient medical record. The consultant must
provide a written report to the requesting practitioner. A reference
to “cc” in the medical record is not sufficient to justify a
consultation.
A consultation may include the diagnostic tests needed to provide
an opinion or advice. If the physician consultant introduces further
therapeutic services, documentation must show that the consultant
recommended a course of action at the request of the attending
physician. Any subsequent services and continuing care rendered
by the consultant cease to be a consultation and become
established patient care services. Initial or subsequent services
rendered by a consultant may make an initial consultation invalid
if records show that patient care was immediately assumed as in a
referral.
A referral is the transfer of total or specific care of a patient from
one physician to another and does not constitute a consultation.
Initial evaluation and subsequent service for a referral are
designated as level-of-service office visits.
Second or confirmatory consults are coded as the appropriate E/M
for the setting and type of service.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)
11-11

Coding Policies and Guidelines (Medical Services)
New and Established
Patients
A new patient is one who has not received any professional
services from the provider or another provider of the same
specialty who belongs to the same group practice within the past
three years.
An established patient is one who has received services from the
provider or another provider of the same specialty who belongs to
the same group practice, within the past three years.
Preventive Medicine Routine examinations for adults and children should be submitted
with CPT codes 99381-99397, according to the age of the patient.
The routine nature of the examination should also be indicated by
the ICD-9-CM code submitted (usually a V-code). Illness and
injury-related visits should be submitted with the office or
outpatient evaluation and management codes 99201-99215 with
the appropriate ICD-9-CM code indicating the illness, injury,
symptom, or complaint.
11-12
The ICD-9-CM code indicates the purpose of performing the
examination. Examinations performed in the absence of
complaints should be billed as preventive medicine to be
compatible with the ICD-9-CM code submitted.
Providers can bill both an E/M code and a preventive medicine
code when a patient goes in for a routine exam and an
illness/problem that is significant enough to require additional
work is found or addressed. In this case, providers may bill 99381-
99397 with a routine diagnosis code and an illness E/M code
99211-99213 with a -25 modifier and an illness diagnosis code.
The -25 modifier indicates a significant, separately identifiable
evaluation and management service by the same physician on the
day of a procedure or service. The appropriate level of E/M should
be submitted.
Generally, a level 4 or 5 illness E/M (99214, 99215) is not allowed
in conjunction with a preventive E/M. Because a level 4 or 5
would require significant additional work, it would seldom be
appropriate to bill both. Denials can be appealed, but would
require documentation to support both E/M services.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)

Preventive Medicine
(continued)
Coding Policies and Guidelines (Medical Services)
The documentation for the E/M must not be combined into or be
part of the documentation for the preventive physical. The
problem(s) addressed must be significant enough to require
additional work. All key components for the level E/M reported
must be met and supported.
Developmental testing, 96110 or 96111, is considered part of an
age appropriate preventive medicine E/M and as such, will deny if
billed in addition to the exam. Exceptions are made only for our
Public Program members (PMAP and MNCare).
Hospital Discharge Hospital discharge services, 99238 or 99239, can only be billed
when services are performed on the actual date the patient left the
hospital. A discharge is not billable for a patient’s death.
Allergy Testing Allergy testing (95004-95075) refers to the evaluation of selective
cutaneous and mucous membrane tests to assist in the
determination of appropriate immunotherapy.
Allergy
Immunotherapy
Submit the number of services in accordance with the CPT
description.
Allergy tests and their interpretation are a single entity; do not
submit separately. An office visit with the modifier –25 may be
submitted in addition to allergy testing only when additional
identifiable services are provided.
Code 95115 should be submitted with one unit of service when
one injection is given.
Code 95117 should be submitted with one unit of service when
multiple injections are given (regardless of the number of
injections).
Codes 95120-95134 should be submitted with one unit of
service. 95145-95180 should be submitted with the number of
services in accordance with the CPT description.
Codes 95115 and 95117 include professional services
necessary for allergen immunotherapy.
A level-of-service office visit with modifier –25 may be submitted
in addition to an allergy injection only when additional identifiable
services are provided.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)
11-13

Coding Policies and Guidelines (Medical Services)
Anticoagulation Clinic-
S9401
Blood, Occult, Feces
Screening
Cardiovascular
Stress Test
11-14
Blue Cross will accept code S9401 for scheduled visits to an
anticoagulation clinic (S9401 – anticoagulation clinic, inclusive of
all services except laboratory tests, per session). This service will
be treated and reimbursed the same as the evaluation and
management (E/M) code 99211. Code S9401 will be subject to an
office call copay.
Code S9401 will not be allowed in addition to an E/M, unless the
E/M represents a significant separately identifiable service. If so,
the E/M should be appended with the –25 modifier and the
appropriate diagnosis linked. Additionally, some contracts may not
allow the service and/or code. For example, ‘S’ codes are not
accepted for our Medicare products.
Codes 82270 (blood, occult; feces, consecutive collected
specimens with single determination) is to be submitted with one
unit of service.
This screening typically tests three specimens, but units of service
should reflect the series, not number of specimens.
The date of service submitted should be the date the test card is
returned to the clinic.
Codes 82271 and 82272 are also limited to one unit of service.
Code 93015 is the global code for a cardiovascular stress test,
which includes both the professional component (interpretation,
report, and physician monitoring) and the technical component
(tracing). Submit code 93016 for physician supervision only,
without interpretation and report. Submit code 93017 for the
technical component only. Submit code 93018 for the professional
component only, which includes interpretation report and
physician monitoring. Submit prolonged services (codes 99354-
99357) only if acute intervention is required beyond routine
physician monitoring during the test.
The monitoring of a patient by a physician during a cardiovascular
stress test is considered an integral part of the professional
component of the test and not reimbursable as a separate service.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)

Chemotherapy
Administration
Coding Policies and Guidelines (Medical Services)
Chemotherapy administration codes are used for services of a
physician or qualified assistant employed by and under the
supervision of a physician. The preparation of the chemotherapy
agent(s) and related supplies are included in the code for
administration of the agent(s). Use the CPT codes below:
Codes 96401-96542 and 96549 cover chemotherapy
administration. Specific Level II HCPCS codes should be used
to identify the chemotherapy drug(s) utilized.
When billing a dosage higher than that listed in the HCPCS
Manual, use the units field to indicate a higher dosage.
For example: The common dosage for J9070 is 100 mg. but 490
mg. was administered. Submit five units of service (round up the
dosage).
Codes J8999 or J9999 should be submitted only if no specific
HCPCS code exist. Specify the drug, dosage and NDC code.
When billing an unlisted code, the unit should always be ‘1’.
Chemotherapy codes may be independent of the patient’s office
visit. An office visit with modifier –25 may be submitted in
addition to or subsequent to chemotherapy administration only
when additional identifiable services are provided.
Professional charges and codes for chemotherapy administration
should not be submitted when services are administered by
hospital or home health agency personnel.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)
11-15

Coding Policies and Guidelines (Medical Services)
Chemical Dependency
Assessment
Often providers perform chemical dependency assessments when a
court of law orders an evaluation or a family member requests one.
Under circumstances like these, providers may submit the
following diagnosis code:
V79.1, screening for alcoholism – use when an alcohol or
chemical dependency assessment or evaluation reveals no
illness, abuse, or dependency.
Services billed with a V79.1 code will apply to the member’s
chemical dependency benefit limit.
CHF Telemonitoring Blue Cross allows coverage for telemonitoring of patients with
congestive heart failure (CHF).
11-16
How CHF Telemonitoring Works
CHF telemonitoring utilizes a computerized scale that is placed in
the patient’s home. The scale weighs the patient and presents a
series of questions to be answered. The data is scored and
transmitted to the physician’s office. An exception report
documents and stores the patient data. Based on the preset
parameters (weight range/criteria) the clinic may be alerted to
contact the patient for additional evaluation and/or intervention.
Reimbursement Requirements
The telemonitoring scale is eligible only as a rental item. The
vendor is responsible for installation, maintenance and update of
the system. Daily monitoring of the transmitted data and
interaction with the patient is the responsibility of the clinical
practitioner(s). Blue Cross assumes that 30 cumulative minutes, or
more, are spent per month performing these activities. To
minimize administrative expenses, we request collection and
interpretation services to be billed on a monthly basis. However,
each interaction with the patient should be reported as one unit.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)

CHF Telemonitoring
(continued)
Billing Guidelines
Coding Policies and Guidelines (Medical Services)
Professional claim format (837P)
Place of service code 11 (clinic)
Submit one claim per month – for scale rental, the date of
service is first date of the month or first date of rental
HCPCS Codes:
S9109 – Congestive heart failure telemonitoring,
equipment rental, including telescale, computer system and
software, telephone connections, and maintenance, per
month
99091 – Collection and interpretation of physiologic data
(e.g., ECG, blood pressure, glucose monitoring) digitally
stored and/or transmitted by the patient and/or caregiver to
the physician or other qualified health care professional,
requiring a minimum of 30 minutes of time
Units:
S9109 - One unit per month for equipment rental
99091 - Total interactions per month (calculated one unit
per patient interaction)
Selected Blue Plus members with congestive heart failure (CHF)
and/or chronic obstructive pulmonary disease (COPD) can receive
telemonitoring services rendered by a participating homecare
agency through their disease management program.
Homecare agencies, physicians and care coordinators may refer a
member with CHF and/or COPD to the telemonitoring program.
Members with established homecare services preferably will
remain with the same homecare agency for telemonitoring services
to ensure continuity of care. Homecare agencies will be
responsible for coordinating the entire telemonitoring program
with the member and physician. Coordination would include:
installation/de-installation, troubleshooting equipment, training,
setting parameters and oversight. We expect face-to-face skilled
nurse visits to decrease due to telemonitoring.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)
11-17

Coding Policies and Guidelines (Medical Services)
CHF/COPD
Telemonitoring
Services for
SecureBlue
(continued)
11-18
Eligibility
This service is currently available only to SecureBlue SM (HMO
SNP) members with diagnosis of CHF and/or COPD who have a
history of hospitalization or emergency room visits in the
preceding twelve months. The alpha prefix for these members is
XZS.
Prior Authorization
These services must be prior authorized by a case manager in the
integrated health management government programs department.
The department’s phone number is 1-800-711-9868.
Coding and Reimbursement
Participating homecare agencies may bill Blue Plus for both
monthly rental of telemonitoring equipment and collection and
interpretation of telemonitoring data.
The following codes should be utilized on the institutional claim
format (837I) for these services:
Telemonitor Rental
Rental should be billed to Blue Plus monthly by either the
homecare agency or the contracted vendor supplying the
monitor. However, only one organization may bill.
Rev.
Code
Description HCPCS Description Reimburs.
0291 Durable
medical
equipment,
rental
S9109 Congestive heart
failure
telemonitoring,
equipment rental,
including telescale,
computer system
and software,
telephone
connections, and
maintenance per
month
$88 per
month
(excludes
any
applicable
MinnesotaC
are tax)
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)

CHF/COPD
Telemonitoring
Services for
SecureBlue
(continued)
Coding Policies and Guidelines (Medical Services)
Data Collection and Interpretation
Services should be billed utilizing one unit per month.
Rev.
Code
0780 Telemedicine
– general
classification
Description HCPCS Description Reimburs.
99091 Collection and
interpretation of
physiologic data
(e.g.,
ECG, blood
pressure, glucose
monitoring)
digitally stored
and/or transmitted
by the patient
and/or caregiver
to the physician or
other qualified
health
professional,
requiring a
minimum of 30
minutes of time
$71.48
per month
(excludes
any
applicable
Minnesota
Care tax)
Day Treatment Submit one unit of service per hour for day treatment programs for
behavioral health diagnoses (H2012). Include the actual time of
therapy on the claim also. Refer to the Behavioral Health section
for additional information.
Diabetic Education Blue Cross recommends submission of HCPCS codes G0108 and
G0109 for a diabetes education program that meets the National
Standards for Diabetes Self-Management Education and obtains
recognition status from the American Diabetes Association (ADA)
or program accreditation from the American Association of
Diabetes Educators (AADE); however, program recognition or
accreditation does not guarantee reimbursement of treatment
which includes Diabetes Self-Management Training, services must
be within the scope of an individual practitioner’s registration,
license and training.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)
11-19

Coding Policies and Guidelines (Medical Services)
E-Care Visits Blue Cross allows coverage of certain internet E/M visits called E-
Care visits.
11-20
Description
E-Care is a term used to describe limited healthcare services
provided over the Internet. E-Care may also be referred to as
online medical evaluations, online visits, E-visits, E-consultations,
or virtual visit.
E-Care is a member initiated online evaluation and management
(E/M) visit provided remotely to patients via the Internet. This
visit is used to address non-urgent medical symptoms including
medication and prescription refills or renewals and review of lab
and test results. E-Care visits are not normally ‘real-time’. The
provider responds to the patient’s issue within a prescribed time
limit (usually within 24 hours).
Coverage Criteria
Services obtained from the rendering practitioner by means of
online email communication via the Internet may be eligible for
coverage for non-urgent care when ALL of the following criteria
are met:
The individual initiating the E-Care visit is an established
patient of the provider and has previously received face-to-face
treatment
In the judgment of the practitioner, the E-Care visit is
medically necessary and involved sufficient resource use, time
and complexity to warrant separate recognition as a unique
event
Written documentation related to the service must be included
in the patient’s medical record and should include the
following:
Documentation must support, at minimum, a 99212 level
E/M
Medical information exchange, assessment, and plan of
treatment/care (e.g., symptoms, counseling)
Services must be billed under the rendering practitioner’s
provider number or NPI
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)

E-Care Visits
(continued)
Qualifying Criteria
Coding Policies and Guidelines (Medical Services)
Qualifying criteria for reimbursement of online services are as
follows:
Practitioner responds within on business day AND one or more
of the following:
Patient describes new symptoms and is requesting intervention
and/or advice from practitioner to treat new symptoms
Patient describes ongoing symptoms from a recent acute
problem or chronic health problem and is requesting
intervention and/or advice from practitioner to treat ongoing
acute problem or chronic health problem
Evidence that practitioner is giving substantive medical advice,
revising treatment plan, prescribing/revising medication,
recommending additional testing, and/or providing self care/
patient education information for new and/or chronic health
problem
Evidence that practitioner is making a new diagnosis and is
prescribing new treatment
Patient requesting interpretation of lab and/or test results with
evidence that practitioner is providing substantive explanation
and recommendations to modify treatment plan, revising
medications, etc.
Evidence that practitioner is providing extended personal
patient counseling that is changing the course of treatment and
impacting the potential health outcome.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)
11-21

Coding Policies and Guidelines (Medical Services)
E-Care Visits
(continued)
11-22
Billing/Coding Information
CODING: 99444 or 98969
99444 – Online evaluation and management service
provided by a physician to an established patient, guardian,
or health care provider not originating from a related E/M
service provided within the previous 7 days, using the
internet or similar electronic communications network
98969 – Online assessment and management service
provided by a qualified non-physician health care
professional to an established patient, guardian, or health
care provider not originating from a related assessment and
management service provided within the previous 7 days,
using the internet or similar electronic communications
network
COPAY: Code 99444 or 98969 is subject to the member’s
office call copay.
CLAIM FORMAT: Billed on the professional claim format-
837P.
UNITS: One (1). Reimbursement for online medical
evaluations is limited to one per day.
PROVIDER NUMBER: An individual provider number or
NPI is required. Code 99444 is limited to MDs. Code 98969 is
limited to PA, NP, and CNS-Medical practitioners.
EDITS: An E-Care visit, 99444 or 98969, will not be allowed
on the same day as another E/M visit. Code 99444 or 98969
will deny as mutually exclusive to these other services. An E-
Care visit will not be allowed as a routine follow-up to surgical
care.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)

E-Care Visits
(continued)
Not Covered:
Coding Policies and Guidelines (Medical Services)
E-Care services are not covered when provided for the following:
Provider-initiated e-mail
Appointment scheduling
Refilling or renewing existing prescriptions without substantial
change in clinical situation
Scheduling diagnostic tests
Reporting normal test results
Updating patient information
Providing educational materials
Brief follow-up of a medical procedure/service to confirm
stability of the patient’s condition without indication of
complication or new condition including, but not limited to,
routine global surgical follow-up.
Brief discussion to confirm stability of the patient’s chronic
condition without change in current treatment.
When information is exchanged and the patient is subsequently
asked to come in for an office visit
A service that would similarly not be charged for in a regular
office visit
Reminders of scheduled office visits
Requests for a referral
Consultative message exchanges with an individual who is
seen in the provider’s office immediately afterward
Clarification of simple instructions
Note: The following is not an all-inclusive list. E-Care visits may
be denied for reasons other than noted below.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)
11-23

Coding Policies and Guidelines (Medical Services)
E-Care Visits
(continued)
Program Exceptions:
Benefits are determined by the individual member contract
language in effect at the time services were rendered. Check for
patient benefits before services are rendered.
The following groups do not provide for coverage of E-Care visits:
Federal Employee Program (FEP)
Medicare Supplements
PMAP/MNCARE
Some self-insured groups
Ear Wax Removal Ear wax removal (removal of impacted cerumen) is by CPT
definition a “separate procedure”. Codes designated as separate
procedures should not be reported in addition to the code for the
total procedure or service of which it is considered an integral
component. The denial however, may vary depending on what
code(s) is billed with 69210. For example, code 69210 will deny as
incidental to audiometry evaluation and speech recognition testing,
but if billed with an office visit, the E/M will be denied as
incidental to 69210.
G0101 G0101 (cervical or vaginal cancer screening; pelvic and clinical
breast examination) is an accepted code. However, G0101 will
deny if billed in conjunction with an E/M service.
11-24
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)

Coding Policies and Guidelines (Medical Services)
Immunizations Immunizations are injections separately identified in CPT and
HCPCS Level II (codes 90476-90749, Q2035-Q2039). Submit the
code which describes the immunization administered. It is
inappropriate to code each component of a combination vaccine
separately. The administration code(s) 90460-90461, 90471-
90474, or G0008-G0010 must be reported in addition to the
vaccine and toxoid code(s) 90476-90749, Q2035-Q2039.
Type of
vaccine/toxoid
administration(s)
injection, oral or
intranasal
Immunization Administration Add-ons
The immunization administration codes 90460-90461, 90471-
90474, or G0008-G0010 are reported in addition to the vaccine or
toxoid code(s) 90476-90749, Q2035-Q2039. When giving more
than one vaccine/toxoid, multiple administration codes are
reported. But it is important to choose the correct add-on
administration code. The following are the correct reporting of
single and combinations of administration codes.
Although the administration services 90472 and 90474 are
considered add-on codes, the modifier 51 does not apply to these
services and should not be reported with these codes.
Is there more
than one vaccine/
toxoid?
Is
counseling
included?
No Yes 90460
Correct administration code(s)
injection No No 90471, G0008, G0009, or G0010
injection, oral or
intranasal
Yes Yes 90460 and 90461 (X # of add’l
vaccines/toxoid components)
injection Yes No 90741, G0008, G0009, or G0010 and
90472 (X # of add’l vaccines/toxoid
components)
oral or intranasal No No 90473
oral or intranasal Yes No 90473 and 90474 (X # of add’l
vaccines/toxoid components)
injection and
oral/intranasal
Yes No 90471, G0008, G0009, or G0010 and
90474 (X # of add’l oral/intranasal
vaccines/toxoid components) or
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)
90473 and 90472 (X # of add’l
injected vaccines/toxoid components)
11-25

Coding Policies and Guidelines (Medical Services)
Immunizations
(continued)
11-26
Serum from Department of Human Services
If receiving serum from the Department of Human Services (DHS)
for child immunizations, the provider should bill Blue Cross for
the administration charge only. Providers should submit the
immunization code with an –SL modifier to indicate the serum was
received from DHS. Providers are required to obtain serum from
DHS for all PMAP enrollees. The administration codes 90460-
90461, 90471-90474, or G0008-G0010 must be reported in
addition to the vaccine. If the vaccine code is submitted it should
be reported with a zero charge. Blue Cross will allow the line to be
submitted with a $0.01 charge if the provider’s billing systems or
services cannot accommodate a zero charge.
Minnesota Health Care Programs (MHCP) payment for
vaccine administration code 90461
Blue Plus is following the DHS guidelines for payment of vaccine
administration. Based upon these guidelines, only the single or
first vaccine/toxoid component will be reimbursed for Blue Plus
MHCP members. Blue Plus reminds providers that, effective
January 1, 2011, claim lines submitted for MHCP members with
procedure code 90461 are being denied as part of the basic service.
See DHS provider communication below:
MHCP-covered Immunization Administration
(vaccines/toxoids). Use the following codes to report
immunization administration in conjunction with each single or
combination vaccine/toxoid code reported.
Code Use to report
administration of:
90471 First vaccine
(single or
combination)
90472 Each additional
vaccine
Administration
route
Percutaneous,
intradermal,
subcutaneous,
intramuscular
Percutaneous,
intradermal,
subcutaneous,
intramuscular
MHCP
limitations
Do not use with
90473
Use with 90471
or 90473; list
separately
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)

Immunizations
(continued)
Code Use to report
administration of:
90473 First vaccine
(single or
combination)
90474 Each additional
vaccine
90460 Single or first
vaccine/toxoid
component of
combination
vaccine
90461 Each additional
component of
combination
vaccine
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)
Coding Policies and Guidelines (Medical Services)
Administration
route
MHCP
limitations
Oral, intranasal Do not use with
90471
Oral, intranasal Use with 90471
or 90473; list
separately
Any 18 years &
younger
Physician /
health care
professional
counseling
required
Any List
separately
Use only
with 90460
(when
performing
physician/
health care
professional
counseling)
*There is no
additional
reimbursement
for the
administration of
the additional
components of a
combination
vaccine.
11-27

Coding Policies and Guidelines (Medical Services)
Immunizations
(continued)
11-28
*Centers for Disease Control and Prevention (CDC) considers the
VFC administration reimbursement amount to be paid on a per
injection basis, not a per component basis.
DHS website reference
To view the DHS specific information go to the following link:
http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DY
NAMIC_CONVERSION&RevisionSelectionMethod=LatestRe
leased&Redirected=true&dDocName=id_000094
Members impacted
This applies to members enrolled in the following Blue Plus plans:
Product name Group numbers
Blue Advantage (PMAP) 18
years and younger
MinnesotaCare 18 years and
younger
PP021, PP022, PP024, PP025,
PP026, PP027, PP031, PP032,
PP034, PP035, PP036, PP037
PP111, PP112, PP151, PP152
Supplies Used in Conjunction with Immunization
Administrations
Syringes, needles or other supplies (A4206-A4209) used in
conjunction with administering any injection, including
immunizations, are considered integral to that administration and
will be denied as incidental to the administration.
Flu Vaccines
The influenza vaccine codes Q2035-Q2039 were added for
Medicare to identify specific flu vaccine products. Additionally,
Medicare instructed that the existing CPT vaccine code 90658
would no longer be allowed. While our Medicare Advantage plan
will follow Medicare’s requirements, commercial plans will
continue to accept 90658 as well as the new flu vaccine codes.
However, edits will be instituted.
Only one flu vaccine code will be accepted: 90658, Q2035,
Q2036, Q2037, or Q2038. Code Q2039 should not be submitted.
If the vaccine is not specific to the products noted in codes Q2035-
Q2038, Blue Cross expects the code 90658 to be submitted in lieu
of the unlisted code Q2039. As a general policy, claims may be
subject to denial when an unlisted code is submitted when a
definitive code exists. Such would be the case for code Q2039.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)

Immunizations
(continued)
Coding Policies and Guidelines (Medical Services)
Q2035 Influenza virus vaccine, split virus, when administered to
individuals 3 years of age and older, for intramuscular use
(Afluria)
Q2036 Influenza virus vaccine, split virus, when administered to
individuals 3 years of age and older, for intramuscular use
(Flulaval)
Q2037 Influenza virus vaccine, split virus, when administered to
individuals 3 years of age and older, for intramuscular use
(Fluvirin)
Q2038 Influenza virus vaccine, split virus, when administered to
individuals 3 years of age and older, for intramuscular use
(Fluzone)
Q2039 Influenza virus vaccine, split virus, when administered to
individuals 3 years of age and older, for intramuscular use (not
otherwise specified)
90658 Influenza virus vaccine, split virus, when administered to
individuals 3 years of age and older, for intramuscular use
90718 Restriction for MHCP Members
Due to a change in the DHS fee schedule, Blue Plus will not allow
the use of code 90718 following the direction set forth by the
Department of Human Services (DHS). Following is the DHS
communication:
Immunization and Vaccines
MHCP does not cover tetanus and diphtheria toxoids vaccine code
(90718). Use the preservative-free tetanus and diphtheria toxoids
vaccine code (90714) for both preservative and preservative-free
vaccines billing.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)
11-29

Coding Policies and Guidelines (Medical Services)
Billing Options for
Medicare Part D
Vaccines
11-30
There is an online option for processing Medicare Part D vaccine
claims electronically. eDispense Part D Vaccine Manager, a
product of Dispensing Solutions Inc. (DSI), is a web portal that
provides physicians with real-time claims processing for in-office
administered vaccines. This system also allows providers to
electronically bill for Part D vaccine administration charges.
eDispense Part D Vaccine Manager allows physicians to bill Blue
Plus (through its pharmacy benefit manager, Prime Therapeutics)
online for all Part D vaccines like Zostavax, on behalf of
SecureBlue, MedicareBlue SM Rx (PDP) and MedicareBlue PPO
(Regional PPO) members.
Physicians can submit claims for Part D vaccines and/or Part D
vaccine administration in two ways: either electronically through
the eDispense website or by using a HICF-1500 and following a
paper claims process.
Enrolled with DSI
If you have enrolled with DSI (Part D electronic clearinghouse) to
use their eDispense claims system, you can submit claims for
vaccines and vaccine administration through their website. This
website will also allow you to check member eligibility for various
Part D vaccines, as well as to determine the applicable member
copays, if any.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)

Billing Options for
Medicare Part D
Vaccines (continued)
Additional Information
Coding Policies and Guidelines (Medical Services)
For more information on eDispense and how to sign up to use that
system, please visit: https://enroll.edispense.com/ws_enroll or
call DSI at 1-866-522-3386. You can also go to bluecrossmn.com
and type “eDispense” in the search option.
Paper Claims
If you decide not to enroll in eDispense, you can use a HICF-1500
form to submit claims for vaccines and administration. If you
submit a paper claim, it must include:
NDC number for the vaccine
quantity
a days supply is reported using (1) unit
Paper claims for SecureBlue members can be submitted to:
Blue Plus
P.O. Box 64813
St. Paul, MN 55164
For the regional products, MedicareBlue Rx or MedicareBlue
PPO, please use the name of the product as the addressee when
submitting paper claims:
MedicareBlue Rx or MedicareBlue PPO (whichever is
appropriate)
P. O. Box 64813
St. Paul, MN 55164
If you have questions regarding claims submitted for the regional
products, please call the member services number on the back of
the member’s ID card.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)
11-31

Coding Policies and Guidelines (Medical Services)
Billing Options for
Medicare Part D
Vaccines (continued)
Questions?
Enrollment and claims processing, call Dispensing Solutions’
customer support center at 1-866-522-3386.
Blue Plus, contact provider service at (651) 662-5200 or toll free at
1-800-262-0820.
MedicareBlue PPO, contact 1-888-457-3009. Links to current
medical policies are available in the provider section of our
website, www.YourMedicareSolutions.com.
Injections Therapeutic or diagnostic injections may be subcutaneous,
intramuscular, intra-arterial, or intravenous. These codes do not
include injections for allergen immunotherapy or immunizations.
11-32
Injectable Drug
Submit the HCPCS Level II code that best describes the injection
given in terms of the drug and dosage. Codes for injections include
the charge for the drug only. When the dosage given is greater than
that listed, use the units field to specify the appropriate number of
units according to code definition found in the HCPCS manual.
For example:
The patient received 8 mg. of haloperiodol. The common
dosage for haloperiodol (J1630) is “up to 5 mg;” 2 UOS
should be submitted. The dosage is rounded up to the next unit.
The administration charge should be submitted separately.
Codes 96379 and J3490 are for unlisted therapeutic injections. The
drug name and dosage must be included on each claim, as well as
the National Drug Code (NDC) number.
Report the drug name, dosage and NDC starting in the loop
2400/NTE segment narrative field for electronic claims.
Administration
Choose the appropriate administration code for the route of
administration 96365-96379.
It is inappropriate to bill an intravenous injection in addition to an
intravenous infusion on the same date of service when an injection
is administered through the same line as the infusion. The provider
may submit the infusion or the injection, but not both.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)

Coding Policies and Guidelines (Medical Services)
Injections (continued) Units of service reflect the number of injections given.
Appealing Unlisted
Drug Allowances
If an office visit is submitted on the same day of the subcutaneous
or intramuscular injection (96372-96376), the administration
would be included in the E/M and will deny if submitted
separately.
Supplies used in conjunction with therapeutic administrations
Syringes, needles or other supplies (A4206-A4209) used in
conjunction with administering any injection, including therapeutic
or diagnostic, are considered integral to that administration and
will be denied as incidental to the administration.
Surgical Injections
Performed as stand-alone procedures/services, the injections
should be submitted with the appropriate CPT code for the
administration of the injection. In addition, submit the HCPCS
Level II code for the drug. If no specific HCPCS code exists for
the drug, submit J3490 with a narrative indicating the drug name,
dosage and NDC.
When surgical injections are performed as part of a surgical
procedure, submit the HCPCS Level II code for the drug. The
administration of the injection is considered part of the surgical
procedure itself and should not be submitted separately.
Unlisted drug codes, such as J3490, should only be submitted if
there is no other code that describes the drug given. All unlisted
drugs must be submitted with a narrative, dosage and NDC, and
are manually priced. There may be times when the invoice cost of
the drug may be significantly higher than our allowance. In this
case, a provider may submit an appeal for additional
reimbursement using the normal appeal process as described in
Chapter 10, “Appeals of Processed Claims.” To facilitate the
appeal review, the drug invoice must be submitted with the appeal
for consideration. Additional reimbursement will not be considered
without the invoice.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)
11-33

Coding Policies and Guidelines (Medical Services)
Infusion Therapy Infusion therapy as described below excludes chemotherapy. For
prolonged intravenous or subcutaneous infusions performed in the
office or clinic, submit CPT codes 96365-96371 for the
administration and the appropriate HCPCS Level II code for the
drug. When billing a higher dosage than listed in the HCPCS
Manual, use the units field to indicate the higher dosage. The CPT
code includes the administration and supplies. Submit code J3490
with a narrative indicating the drug name, dosage and NDC if a
specific HCPCS code for the drug does not exist. Only a unit of
one (1) should be reported when submitting an unlisted drug code.
Injection and Infusion
Services Restrictions
Codes 96365-96371 typically require direct physician supervision
for any or all purposes of patient assessment, provision of consent,
safety oversight, and intra-service supervision of staff.
Professional charges for infusion therapy should not be submitted
when the service is administered by the hospital or the home health
agency personnel. Do not use these codes to indicate intradermal,
subcutaneous, intramuscular, or routine IV injections, or
chemotherapy.
Blue Cross will not allow professional 837P charges for
therapeutic, prophylactic, diagnostic injection and infusion CPT®
codes (96360-96379) when rendered in certain places of service.
Professional services (837P) submitted with a facility place of
service (such as 21, 22 or 23), will deny as provider liability.
Dispensing Fees Drug dispensing fees, Q0510-Q0514, are non-covered and will
deny as provider liability. Coverage may be allowed for our
Medicare members.
Interpreter Services Interpreter services are not separately billable or reimbursed for
most members.
Transfusion—Blood
and Blood Products
11-34
Refer to the Public Programs section of this chapter for interpreter
service guides for Public Program members.
Transfusion of blood and/or blood products is submitted with code
36430 when administered by a physician or qualified assistant
employed by and under the supervision of a physician. Preparation
of blood and blood products is included in the service for
administration of the agent.
Professional charges/codes for the transfusion of blood or blood
products should not be submitted when administered by hospital or
home health agency personnel. Bill the blood separately with the
appropriate HCPCS code.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)

Coding Policies and Guidelines (Medical Services)
Locum Tenens A substitute physician who takes over another physician’s practice
when that regular physician is absent for specific reasons (e.g.,
illness, maternity leave, military duty or sabbatical) is generally
referred to as a “locum tenens” physician. The services rendered
by the locum tenens physician may be submitted under the absent
physicians’ provider number or NPI. The modifier Q6 should be
appended to these services. Additional or replacement physicians
not substituting for an absent physician must be credentialed and
submit claims with their own NPI.
Natural Family
Planning
The natural family planning (NFP) code H1010 (Non-medical
family planning education, per session) is restricted only to those
participating non-clinic providers contracted as a NFP provider.
Clinics/medical practitioners providing NFP would bill their
services using the appropriate evaluation and management code.
Nicotine Dependence Blue Cross covers services for the treatment of tobacco
dependence. However, coverage for these services depends on the
type of provider submitting the claim, the procedure/service and
diagnosis codes submitted, and the patient’s contract with Blue
Cross. Due to these many variables, exact payment can not be
determined until we receive the claims for processing.
Diagnosis Codes
If the primary reason for the outpatient visit to the clinician is
tobacco use, claims should be submitted with one of the following
diagnosis codes:
305.1 tobacco use disorder
V15.82 history of tobacco use
Procedure/Service Codes
Clinicians should submit the HCPCS code that reflects the service
furnished. Claims may process differently depending on the code
submitted. The difference reflects the application of the member’s
contract benefits.
Evaluation and Management (E/M) codes 99201-99215:
Claims submitted using these problem-related visit codes will
process according to the illness portion of the patient’s
contract.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)
11-35

Coding Policies and Guidelines (Medical Services)
Nicotine Dependence
(continued)
11-36
E/M codes 99241-99245: Claims submitted using these
consultation codes will process according to the illness portion
of the patient’s contract when submitted with a tobacco
diagnosis.
E/M codes 99401-99404: Claims submitted using these
preventive counseling codes will process according to the
preventive portion of the patient’s contract. These codes may
also be covered under the Patient Protection and Affordable
Care Act (PPACA) otherwise known as health care reform
(HCR) and as such, will be processed according the preventive
portion of the patient’s contract.
Codes 99406 and 99407: Claims submitted using these
counseling visit codes will process according to the illness
portion of the patient’s contract. These codes may also be
covered under the Patient Protection and Affordable Care Act
(PPACA) otherwise known as health care reform (HCR) and as
such, will be processed according the preventive portion of the
patient’s contract.
Code S9453 for stop-smoking classes is generally not an
eligible service under the patient’s contract; however, may be
covered under the Patient Protection and Affordable Care Act
(PPACA) otherwise known as health care reform (HCR) and as
such, will be processed according the preventive portion of the
patient’s contract.
E/M codes 99384-99387 and 99394-99397: These
comprehensive preventive medicine services include
counseling/anticipatory guidance/risk factor reduction
interventions. Tobacco cessation counseling is part of a
comprehensive preventative medicine evaluation. Therefore it
is not separately reportable under these codes.
Psychiatric codes 90804-90862: Claims submitted using these
codes will process according to the substance abuse portion of
the patient’s contract.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)

Nicotine Dependence
(continued)
Revenue Codes Used
by Facilities 0944 or
0945
Eligibility to Bill for
Specific
Procedures/Services
Coding Policies and Guidelines (Medical Services)
Group counseling codes 99411-99412 will process according
to the illness portion of the patient’s contract when submitted
with a tobacco diagnosis; however, may be covered under the
Patient Protection and Affordable Care Act (PPACA)
otherwise known as health care reform (HCR) and as such, will
be processed according the preventive portion of the patient’s
contract.
For questions regarding “incident to” services please refer to
Chapter 8 of this manual.
Codes for reporting patient documentation or supplemental
tracking for performance measurement (4000F-4001F) may be
submitted. These are zero-billed and zero-allowed codes.
Facilities such as hospitals, skilled nursing facilities, and
residential treatment centers, must bill for tobacco use under
revenue codes 0944 (drug rehabilitation) or 0945 (alcohol
rehabilitation). Claims submitted using these codes will process
according to the substance abuse portion of the patient’s contract.
Standard guidelines regarding provider eligibility apply to
procedures/services submitted with a tobacco diagnosis. Provider
eligibility depends on the provider’s scope of practice and the type
of procedure/service being billed. For example, consultation codes
are generally only allowed when performed by a MD; however,
evaluation and management codes may be eligible if billed by a
qualified practitioner such as a Nurse Practitioner, or Physician
Assistant. Some procedure/service codes specific to mental health
and chemical dependency may have to be performed by a qualified
mental health provider.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)
11-37

Coding Policies and Guidelines (Medical Services)
Coverage for Tobacco
Treatment Medications
Noncovered Tobacco
Treatments
Medication Therapy
Management (MTM)
11-38
All fully insured Blue Cross plans with drug coverage cover stopsmoking
medications. The same copayments and deductibles
apply. With a physician’s prescription these patients are eligible
for Zyban and/or any FDA-approved nicotine replacement therapy
drug (patch, gum, lozenge, inhaler, and nasal spray).
Note #1: In order to trigger this benefit, the patient does need a
physician’s prescription even if the medication is available over
the counter (except as described below in Note #2).
Note #2: Blue Cross wants to encourage people to use both
counseling and medications. Fully insured members who choose to
enroll in the Stop-Smoking Program can trigger their benefit for
either patch, gum, or lozenge without a physician’s prescription if:
they enroll in our free Stop-Smoking Program (phone-based
counseling),
they have pharmacy benefits that cover FDA-approved OTC
NRT and these benefits are administered through Prime
Therapeutics, Blue Cross’ pharmacy benefit manager, and
the Quit Coach at the Stop-Smoking Program determines that
the member can safely take the medications.
Each self-insured group account chooses whether or not if will
cover prescription and/or over-the-counter stop-smoking aids.
Thus coverage varies greatly among self-insured groups. Your
patients who have Blue Cross coverage through a self-insured
group should call the customer service number on the back of their
member ID card to determine if they have coverage for tobacco
treatment medications and what restrictions might apply. If you
have questions you may contact Blue Cross provider services.
Refer to Medical Policy X-21 for information regarding treatments
that are considered INVESTIGATIVE or ineligible for treatment
of tobacco use, dependence, and withdrawal.
Medication Therapy Management services are a covered benefit
for Prepaid Medical Assistance Program (PMAP) Public Programs
members.
Eligible providers must be enrolled through DHS
Eligible providers must be enrolled through DHS as a certified
MTM pharmacist. Services should be submitted on an 837P claim
format with the following codes:
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)

Medication Therapy
Management (MTM)
(continued)
Coding Policies and Guidelines (Medical Services)
Code Definition Allowed Frequency
99605 Medication Therapy Management
Service(s) provided by a
pharmacist, individual face to face
with patient, with assessment and
intervention if provided; initial 15
minutes, new patient.
99606 Medication Therapy Management
Service(s) provided by a
pharmacist, individual face to face
with patient, with assessment and
intervention if provided; initial 15
minutes, established patient.
99607 Medication Therapy Management
Service(s) provided by a
pharmacist, individual face to face
with patient, with assessment and
intervention if provided; each
additional 15 minutes (list
separately in addition to code for
primary service)
Pricing and programs applicability
1 per enrollee per
year
Up to 7 per enrollee
per year
Up to 4 per enrollee
per date of service
Blue Cross has incorporated DHS rates in the usual pricing
methodology for Public Programs for these codes. This
information applies to the following programs and group numbers:
Prepaid Medical Assistance Program (PMAP & GAMC) – all
groups beginning with PP0 (Members with Medicare must get
these services through their Medicare Part D plan).
SecureBlue – all groups beginning with PP2 (Members with
Medicare must get these services through their Medicare Part
D plan for Medicare-covered services).
Minnesota Senior Care – all groups beginning with PP0
(Members with Medicare must get these services through their
Medicare Part D plan).
MinnesotaCare – Expanded (PP111, PP112, PP151, PP152),
Basic Plus (PP161, PP162, PP163, PP164), Basic + One
(PP121, PP122), and Basic + 2 (PP131, PP132, PP141,
PP142).
This benefit is not covered under the Limited Benefit Set (PP171,
PP172).
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)
11-39

Coding Policies and Guidelines (Medical Services)
Oral Medication When submitting oral drugs for your Blue Cross patients, use the
procedure/service codes in your HCPCS manual. HCPCS includes
many codes for oral medications and injections that are commonly
dispensed in physicians’ offices.
Non-Physician Health
Care Practitioners
11-40
Use J8499 (prescription drug, oral, nonchemotherapeutic, NOS)
only in limited situations such as after-hours emergency visits,
house calls, or in rural areas where access to a community
pharmacy is limited. Drug name, dosage, and NDC must be
included on each claim.
Benefits cannot be extended for drug samples provided by
pharmaceutical companies.
If the service is rendered by a non-physician healthcare
practitioner that we credential, and/or verify licensure and are
issued individual provider numbers, that practitioner must submit
the services under the individual provider number that Blue Cross
has issued to him or her or NPI.
Some practitioners who are not credentialed or issued individual
provider numbers or NPIs (such as LPN, RN, dietitian), work
under the supervision of a physician. The services must be
submitted under the supervising physician’s provider number/NPI.
The -U7 modifier must be submitted with the procedure/service to
indicate these services. This includes those clinics with a
pharmacist on staff. Services would be billed under the supervising
MD with the -U7 modifier.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)

Practitioners That ARE
Credentialed by Blue
Cross and Issued
Individual Provider
Number/NPIs
Coding Policies and Guidelines (Medical Services)
Acupuncturists (LAc)
Certified Ind. Clinical Social Worker (CICSW)
Certified Marriage and Family Therapist (CMFT)
Certified Nurse Midwife (CNM)
Certified Professional Counselor (CPC)
Chiropractor (DC)
Dentist (DDS, DMD)
Psychologist (PhD., MA, PsyD., MS, EDD)
Licensed Certified Social Worker (LCSW)
Licensed Ind. Clinical Social Worker (LICSW)
Licensed Ind. Social Worker (LISW)
Licensed Marriage & Family Therapist (LMFT)
Licensed Prof. Clinical Counselor (LPCC)
Optometrist (OD)
Physician Assistant (PA)
Physician (MD, DO)
Podiatrist (DPM)
Psychiatric Mental Health Nurse Practitioner (PMHNP)
Registered Nurse Clinical Specialist (CNS)
Registered Nurse Practitioner (NP)
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)
11-41

Coding Policies and Guidelines (Medical Services)
Practitioners that
are NOT Credentialed
by Blue Cross But Are
Issued Individual
Provider Number/NPIs
Counseling and/or Risk
Factor Reduction
Room or Machine Set-
Up Charges
Although the following practitioner types do not go through the
credentialing process, they do require an individual provider
number or NPI for claims submission.
Audiologist
Certified Registered Nurse Anesthetist (CRNA)
Licensed Assoc. Counselor (LAC)
Lic. Assoc. Marriage & Family Therapist (LAMFT)
Licensed Psychological Practitioner (LPP)
Occupational Therapist (OT)
Physician Therapist (PT)
Registered Nurse First Assist (RNFA)
Resident
Social Worker (Levels: LISW, LGSW, LSW,
LMSW, CSW, LSW, LMSW, CISW, CASW)
Speech and Language Therapist
Individual preventive medicine counseling (codes 99401-99404)
are reimbursed per contract benefits. Group preventive medicine
counseling (codes 99411-99412) may be covered under the Patient
Protection and Affordable Care Act (PPACA) otherwise known as
health care reform (HCR).
Room or machine set-up charges are considered to be an integral
part of the procedure/service being done. Do not submit separately
for these services.
Supplies in the Office Supplies in the clinic setting are generally included or part of the
procedure or service. Codes 99070, A4649 and A4550 will be
denied. Other supplies, such as Betadine or alcohol wipes, will
also be denied. Generally, supplies are only allowed separately in
conjunction with approved home health care.
Adjunct CPT Codes Adjunct CPT codes 99024-99060 are designed for the provider to
report special circumstances under which a basic procedure/service
is performed.
Care Plan Oversight
Services
11-42
Blue Cross does not consider these or provider inconvenience fees
as reimbursable services and they are denied as a provider liability.
Care plan oversight services codes 99374-99380 are not
reimbursed by Blue Cross as a separate service from the evaluation
and management codes and will deny as provider liability.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)

Prolonged Physician
Services
Coding Policies and Guidelines (Medical Services)
Blue Cross reimburses face-to-face prolonged physician services
codes 99354-99357. Codes 99358-99359 are not reimbursed
(prolonged services without face-to-face patient contact) and will
deny as provider liability.
Telephone Calls Telephone calls, codes 99441-99443 and 98966-98968, are noncovered
services. Calls are considered an integral part of other
services the patient receives (usually an evaluation and
management service) and not separately reimbursable.
Medical Team
Conferences
Televideo
Consultations
Medical conferences without face-to-face patient contact, codes
99367-99368, are not reimbursed, and will deny as provider
liability.
Blue Cross provides reimbursement for certain televideo
consultations. These consultations are also sometimes referred to
as telemedicine or telehealth services. Televideo consultations are
interactive audio and video communications, permitting real-time
communication between a distant site physician or practitioner and
the member, who is present and participating in the televideo visit
at a remote facility.
Coverage of televideo consultations includes consultations, office
visits, psychotherapy, substance use disorders, as well as the codes
allowed per Medicare policy. Facilities may be reimbursed for the
origination fee. Both the consulting physician and the remote clinic
or remote site will submit a claim for their services. The consulting
physician will bill the appropriate CPT evaluation and
management, psychotherapy code, nutrition therapy or follow-up
telehealth consult code. The remote provider will bill for the
originating site facility fee only. This service is billable on either
the professional or institutional claim format.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)
11-43

Coding Policies and Guidelines (Medical Services)
Remote Clinic or Remote
Site
CODING Q3014- Telehealth
originating site facility fee
11-44
0780- Telemedicine, General
Classification
Consulting Physician/Practitioner
Note: The –GT modifier must be appended to
all of the services below.
–GT– Via interactive audio and video
telecommunication systems
99201-99215 – Office or other outpatient
visits
99231-99233 – Subsequent hospital care
services
99307-99310 – Subsequent nursing facility
care services
99241-99255 – Consultations
90801 – Psychiatric diagnostic interview
90804-90809 – Individual psychotherapy
90862-Pharmacologic management
90846 – Family psychotherapy (without the
patient present)
90847 – Family psychotherapy (conjoint
psychotherapy) (with patient present)
90849 – Multiple-family group
psychotherapy
90853 – Group psychotherapy (other than of
a multiple-family group)
90857 – Interactive group psychotherapy
90951-90952, 90954-90955, 90957-90958,
90960-90961 – ESRD related services
96116 – Neurobehavioral status exam
96150-96154 – Individual and group health
and behavior assessment and intervention
G0108-G0109 – Individual and group
kidney disease education services
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)

CODING
(continued)
Remote Clinic or Remote
Site
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)
Coding Policies and Guidelines (Medical Services)
Consulting Physician/Practitioner
CO-PAY None Co-pays would apply
GLOBAL
PERIOD
Televideo Coverage
Exceptions
Not included in the global
surgical period
G0270, 97802-97803 – Individual medical
nutrition therapy
G0406-G0408 – Follow-up inpatient
telehealth consult
G0420-G0421 – Individual and group
kidney disease education services
G0436-G0437, 99406-99407 – Smoking
cessation services
Global surgical package edits apply
Televideo consultations are subject to the terms of the member’s
contract and may not be covered under the member’s health plan.
The Federal Employee Program (FEP) specifically excludes
televideo consultations. Televideo consultations do not include
telephone calls or Internet consultations. Telephone and Internet
consultations are contract exclusions and will be denied.
Unusual Travel Unusual travel charges (99082) are non-covered services and will
deny as provider liability
Urgent Care Clinic-based urgent care services may be billed under the place of
service (POS) 20. The POS code 20 will apply office benefits to
the services if submitted. DO NOT bill a corresponding facility
claim with the revenue code 0456 if already billing for urgent care
on the professional claim (837P). This would be considered
duplicate billing.
Hospital based emergency room urgent care should be billed on
the UB-04 only with the revenue code 0456.
Codes S9083 (global fee urgent care centers) and S9088 (services
provided in an urgent care center) represent where the service was
rendered, not the service itself. Thus, they are not separately
covered and will be denied as part of the primary service (such as
E/M).
11-45

Coding Policies and Guidelines (Medical Services)
Weight Management
Care
11-46
General Guidelines
In general, Blue Cross covers services for the treatment of obesity,
weight management, nutrition, and physical activity counseling.
However, coverage for these services depends on the type of
provider submitting the claim, the procedure/service and diagnosis
codes submitted, and the patient’s contract with Blue Cross. We
encourage you to request that your patients check on their
coverage before extensive services are provided. Due to the many
variables, exact payment can not be determined until we receive
the claim for processing.
Screening and counseling for obesity and counseling for a healthy
diet are covered under the Patient Protection and Affordable Care
Act (PPACA) otherwise known as health care reform (HCR).
The suggested coding for obesity screening and counseling
includes 97802-97804, 99078, 99401-99404, 99411-99412,
G0447, G0449 or S9470 as preventive with 278.00 or 278.01.
The suggested coding for counseling for a healthy diet includes
99401-99404, 99411-99412, 99078, 97802-97804, G0447, S9452,
S9470 as preventive with V65.3.
Refer to the information below for screening and other services not
subject to PPACA. The outline reviews the following seven
categories as they relate to coverage for services related to obesity,
weight management, nutrition, and physical activity counseling.
1. Diagnosis Codes
2. Procedure/Service Codes
3. Eligible Providers
4. Weight Loss Programs
5. Weight Loss Drugs
6. Physical Activity
7. Surgery
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)

Weight Management
Care (continued)
Diagnosis Codes
Coding Policies and Guidelines (Medical Services)
The physician determines if the patient meets the criteria to be
classified as obese. If the patient meets those criteria, two specific
obesity diagnosis codes may be used:
1. 278.00 Obesity, Unspecified
2. 278.01 Morbid Obesity
In addition to the two specific obesity codes, the provider may also
bill for obesity or weight management counseling with routine
diagnosis codes such as:
1. V65.3 Dietary Surveillance and Counseling
2. V70.0 Routine General Medical Examination at a Health Care
Facility.
The obesity diagnosis codes of 278.00. 278.01 and code V65.3 will
cause claims to pay according to the illness portion of the patient’s
contract. All Blue Cross contracts have benefits for illness-related
services. If the claim is submitted with a routine medical exam
code of V70.0, it will pay based on the routine benefits, if any, are
provided by the patient’s contract. Some contracts exclude routine
benefits.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)
11-47

Coding Policies and Guidelines (Medical Services)
Weight Management
Care (continued)
11-48
Claims may be submitted for obesity, weight management,
nutrition counseling etc. with the diagnosis of the underlying
symptom that brought the patient to the provider. For example, the
claim may be submitted with a diagnosis of elevated blood
cholesterol, shortness of breath, or diabetes. These claims will
process according to the medical illness benefit.
Procedure/Service Codes
Services for obesity/weight management counseling may be billed
under E/M codes (99201-99215) provided that those services meet
the components of an E/M service. These E/M codes are
compatible with all causes, illness or routine related, and will pay
according to the diagnosis submitted.
Claims may also be submitted as preventive counseling (99401-
99404). These codes, however, are only compatible with routine
diagnosis codes (e.g., V70.0). Claims submitted with these
procedure/service codes and a routine diagnosis code will process
according to the patient’s preventive benefit, provided the patient
has coverage for preventive services. If CPT codes 99401-99404
were submitted with a diagnosis of obesity (e.g., 278.00) the claim
would reject because the service was incompatible with the
diagnosis.
Medical nutritional therapy codes (97802, 97803, S9470) may be
billed when counseling patients on obesity or weight management.
These codes are compatible with any diagnosis but are most
appropriate or intended for illness or disease-related diagnoses
such as obesity or diabetes. Note that code 97804 is nutritional
therapy in a group setting. Group therapy services are generally
only covered when submitted with diagnosis codes for anorexia,
bulimia, diabetes, congestive heart failure, and some maternity
diagnosis codes.
The FEP contract allows medical nutrition therapy services only
for the following diagnosis codes:
Diagnosis codes 250.XX and 648.XX for diabetes and
gestational diabetes;
Medical nutritional therapy for eating disorders 307.1
(anorexia nervosa) and 307.51 (bulimia nervosa); or
Dietitian assessments as part of a multi-disciplinary eating
disorder evaluation.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)

Weight Management
Care (continued)
Coding Policies and Guidelines (Medical Services)
Nutritionists, Dietitians and other Providers
For many lines of business, Blue Cross pays Minnesota licensed
nutritionists, licensed dietitians, and registered dietitians directly
for services submitted with an eating disorder code 307.1, 307.50
and 307.51. The provider may submit using procedure/service
codes S9470, 97802, 97803, or 97804 based on the service
provided. No referral is necessary for the highest benefit level.
Some self-insured plans, however, may exclude coverage by a
dietitian, so benefits should be verified.
Licensed dietitians and licensed nutritionists can bill for
procedure/service codes S9470, 97802, 97803, G0447 and G0449
for diagnosis codes other than eating disorders. Services provided
by licensed dietitians and nutritionists must be submitted to Blue
Cross using the provider number or NPI of an eligible medical
clinic or hospital. The individual provider number or NPI of the
licensed dietitian or licensed nutritionist must also be submitted on
the claim.
Registered dietitians billing for services outside of behavioral
health diagnosis codes will have those claims denied unless the
services are submitted under the individual provider number of a
supervising physician. The –U7 modifier should also be submitted.
Health educators and exercise physiologists are not recognized as
eligible providers and their services will be rejected if received by
Blue Cross.
Weight Loss Programs
Blue Cross does not cover commercial weight loss programs (e.g.,
Nutra-systems, Jenny Craig, LA Weight Loss, Weight Watchers
etc.) with the exception of the PMAP contract.
Members of MinnesotaCare, BlueAdvantage, SecureBlue do have
limited weight loss programs benefits, including weight
management and nutrition classes.
Weight Loss Drugs
All fully insured groups cover weight loss drugs. Public Program
accounts do not cover weight loss drugs. Each self-insured account
chooses whether or not to cover weight loss drugs. Note that
patients covered by certain State Health Plan products have
specific authorization requirements for weight loss drugs.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)
11-49

Coding Policies and Guidelines (Medical Services)
Weight Management
Care (continued)
11-50
Physical Activity
There are no procedure/service codes specifically for physical
activity counseling. Providers typically bill counseling services for
physical activity as an E/M service (99201-99215) provided that
the counseling meets the components of an E/M service. There is
no specific diagnosis code for physical activity counseling.
Exercise classes (S9451) are generally non-covered.
The provider may also submit codes for preventive counseling
(99401-99404). These codes however, are only compatible with
routine diagnosis codes (e.g., V70.0). Claims submitted with these
procedure/service codes and a routine diagnosis code will process
according to the patient’s preventative benefit, provided the patient
has coverage for preventative services.
Services billed by a personal trainer or an exercise physiologist are
not covered. Claims for their services will be denied as an
ineligible provider, regardless of the procedure/service code and
diagnosis code submitted.
Surgery
Blue Cross has a detailed medical policy, IV-19, regarding
provider and patient eligibility criteria for obesity surgery.
Some groups exclude coverage for obesity surgery in their
contracts. Prior authorization is highly recommended.
Disclaimer: The fine print
This information is designed for reference purposes only and does
not guarantee coverage. Blue Cross will consider each individual
member’s condition and unique circumstances in making coverage
determinations. Blue Cross will also make each determination on a
case-by-case basis and according to the terms and conditions of the
member’s contract, certificate of coverage, or summary plan
description, as applicable, including provisions relating to
exclusions and limitations. If there is a conflict between the
information above and the contract or plan documents, the contract
or plan documents govern.
Blue Cross reviews its policies and coverage periodically and may
make changes in the future.
Any providers who have questions about this information are
invited to contact Blue Cross provider services.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)

Assessment
Management Program
for Fully Insured
Coding Policies and Guidelines (Medical Services)
The Integrated Health Management division of Blue Cross utilizes
a management program called Access Management. The program
only applies to fully insured members with commercial Managed
care (Blue Plus) and preferred provider (Aware ® ) coverage who
are using services at a higher frequency than their known medical
conditions would normally warrant.
Program Details
Members that meet the Access Management program criteria will
be assigned to a specific physician for their primary care needs
who, in turn, will coordinate all their care and medication needs.
The member will also be assigned to a single pharmacy and a
single hospital. Access to specialty care may be discussed with the
Blue Cross access manager assigned to the member. Assignment to
the Access Management program is for 24 months.
Member identification
To see if a member is enrolled in the Access Management Program
check the provider web self-service (PWSS) at providerhub.com
or use the 270/271 Eligibility transaction as noted below. For
provider web self-service, follow the link to the HIPAA benefit
view from the Member Benefit Screen. If the member is enrolled
in AMP, it will be indicated in the HIPAA view screen.
Members enrolled in the program will have the letters AMP on
their member ID card. Members currently enrolled will receive
new member ID cards with AMP on them. As individuals are
enrolled in the program a new member ID card will be issued with
AMP on the card. When members exit the program a new member
ID card will be issued without AMP.
Eligibility
If you are not the assigned physician, pharmacy or hospital for a
member in this program, it may affect claims payment should you
provide services to a member enrolled in this program. If we have
received claims from you within 12 months prior to the member
being placed in this program, you will be notified by telephone
and/or letter of the member’s placement.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)
11-51

Coding Policies and Guidelines (Medical Services)
Assessment
Management Program
for Fully Insured
(continued)
11-52
Eligible services provided to a member in the Access Management
program will only be reimbursed when one of the following
criteria is met:
The service is provided by the member’s assigned provider
The service is of a provider type or type of service that is not
listed as needing Access Management. This includes Durable
Medical Equipment (DME), home care, ambulance services,
mental health or chemical health services.
Eligibility Transaction
The following Loops and Segments will be populated in the 271
eligibility response when the above Eligibility criteria are met.
HIPAA Version 5010
2110C/D – EB (Subscriber/Dependent Eligibility or
Benefit Information)
EB01 = MC (Managed Care Coordinator)
2110C/D – DTP (Subscriber/Dependent Eligibility/Benefit
Date)
DTP01 = “193” (Period Start)
DTP02 = “D8” ( Date Expressed in Format
CCYYMMDD)
DTP03 = CCYYMMDD (Period Start Date)
2110C/D – MSG (Message Text)
MSG01 = Access Management Program
Additional Information
If one of your patients is enrolled in this program, you will be
notified by letter by the access manager. As the primary provider,
you will be coordinating the identified member’s care with the
Blue Cross access manager.
If you have a patient covered by fully insured commercial
coverage who you believe would benefit from the Access
Management program, contact Cathryn Bashore, manager, at
(651) 662-0733 or Jennifer Jaynes, director, at (651) 662-2346.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)

Health Care Home
(HCH)
Health Care Home Guidelines
Coding Policies and Guidelines (Medical Services)
Blue Cross will accept certain claims for payment of health care
home (HCH) care coordination services billed via procedure codes
S0280 or S0281.
The development of health care homes in Minnesota is part of the
health care reform legislation passed in Minnesota in May 2008.
The legislation includes payment to providers for partnering with
eligible patients and families to provide coordination of care.
Blue Plus' Minnesota Department of Human Services (DHS) 2010
Contracts require that individuals with complex or chronic
conditions be able to access services through a certified health care
home. These provisions impact individuals enrolled in Minnesota
Health Care Programs (MHCP), including Blue Advantage,
MinnesotaCare, SecureBlue, Minnesota Senior Health Options
(MSHO), Special Needs Basic Care (SNBC), and Minnesota
Senior Care Plus (MSC+). These health care home provisions also
impact the Minnesota Advantage Health Plan offered by the State
Employee Group.
In addition, Blue Cross will accept certain claims for payment of
certified health care home care coordination services for
Subscribers covered under fully insured group contracts, when
billed via procedure codes S0280 or S0281. The benefit will not be
offered to self-insured groups at this time. Individuals enrolled in
our Platinum Blue Medicare Cost products or Medicare
Supplement products will also not be affected.
What does this mean for you?
Blue Cross will not be pursuing separate contracting
arrangements for HCH services at this time. Payment for
services provided to both commercial subscribers and
Minnesota Health Care Programs enrollees will be made at
your then-current contracted rate of reimbursement for health
services.
Members will not have copayments or coinsurance for HCH
care coordination, except in the case of fully insured
commercial subscribers covered under a health savings account
(HSA), as per Internal Revenue Service requirements (see
below).
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)
11-53

Coding Policies and Guidelines (Medical Services)
Health Care Home
(HCH) (continued)
11-54
To the extent that Blue Cross has global payment arrangements
with providers or other alternative reimbursement
arrangements that already include HCH-type care coordination
arrangements Blue Cross will not give the provider a separate
payment under the HCH requirement.
Enrollment in a health care home is voluntary and based on
information collected and documented by the provider.
Providers are required to maintain a registry of health care
home participants. Health plans have worked with the AUC to
develop standardized billing codes for health care home
services. Individuals are not prohibited from being enrolled in
more than one HCH, but health plans are only required to pay
for a single HCH for each member.
Blue Cross will comply with health care home legislation in
the processing of care coordination fees incurred by our
impacted State Health Plan members. There will be no cost
sharing for either the Minnesota Advantage Health Plan or the
Advantage Consumer Directed Health Plan offered by the State
Employee Group Insurance Plan. Health care home care
coordination will not be a covered service for members of the
Public Employee Insurance Plan.
Because Blue Cross has no administratively feasible way to
identify a member’s “real” HCH, we will pay the first claim
that we receive each month. Additional claims will not be paid.
Certified health care home care coordination services
Certified health care home care coordination services will be
accepted for fully insured commercial business and Minnesota
Health Care Programs for reimbursement under procedure codes
S0280 or S0281, subject to the following limitations:
Subscribers who are not covered under a health savings
account (HSA) plan:
1. For code S0280: Allow once per 12 months for each
patient/provider combination. No patient out of pocket
should be applied. The code will be allowed per provider
contract. Code S0280 billed more than once per 12 months
for each patient /provider combination will be denied with
Claim Adjustment Reason Code 119 and Remark Code
M90.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)

Health Care Home
(HCH) (continued)
Coding Policies and Guidelines (Medical Services)
2. For code S0281: Allow once per month for subsequent
months. No patient out of pocket should be applied. The
code will be allowed per provider contract. Code S0281
billed more than once per month for each patient will be
denied with Claim Adjustment Reason Code 119 and
Remark Code M86.
Subscribers who are not covered under an HSA plan members:
1. For code S0280: Allow once per 12 months for each
patient/provider combination. Patient
deductible/coinsurance will apply per Internal Revenue
Service (IRS) regulations. The code will be allowed per
provider contract. Code S0280 billed more than once per
12 months for each patient /provider combination will be
denied with Claim Adjustment Reason Code 119 and
Remark Code M90.
2. For code S0281: Allow once per month for subsequent
months. Patient deductible/coinsurance will apply per IRS
regulations. The code will be allowed per provider contract.
Code S0281 billed more than once per month for each
patient will be denied with Claim Adjustment Reason Code
119 and Remark Code M86.
Coding Submission
The following coding submission guides were developed by the
AUC Medical Code TAG and approved by the AUC Operations
Committee. This information is found in the 5010 version of the
837P MN Companion Guide, Table A.5.1, Chapter 12.
The Health Care Home Payment Methodology Steering
Committee has determined that five levels of patient complexity
should be recognized for health care home payment purposes. In
addition, the complexity level determination must take into
account two supplemental factors (non-English speaking, and
major active mental health condition). In order to achieve the goals
of reporting five levels of patient complexity, as well as two
additional supplemental complexity factors, additional qualifiers
(modifiers or condition codes) are needed.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)
11-55

Coding Policies and Guidelines (Medical Services)
Health Care Home
(HCH) (continued)
11-56
The Medical Code TAG recommends that interim coding as shown
below be used until new modifiers and/or condition codes can be
created at the national level to differentiate health care home
patient complexity levels. The proposed interim solution is to use
U modifiers, in addition to existing TF and TG modifiers, with the
following two S codes: S0280 – medical home program,
comprehensive care coordination and planning, initial plan; and
S0281 – medical home program, comprehensive care coordination
and planning, maintenance.
Proposed interim solution: Use U modifiers in conjunction with
medical home S codes as shown below:
Patient
Complexity
Level Modifiers
Low (no major
conditions)
Non English
Speaking
No modifier U3 U4
Basic U1 U3 U4
Intermediate TF U3 U4
Extended U2 U3 U4
Complex
(most major
conditions
TG U3 U4
Definitions of U codes
Active Mental
Health
Condition
U1 – Care coordination, basic complexity level (used with
S0280 - S0281)
U2 – Care coordination, extended complexity level (used with
S0280 - S0281)
U3 – Care coordination, supplemental factor; non-English
language (used with S0280 – S0281)
U4 – Care coordination, supplemental factor; Major Active
Mental Health Condition (used with S0280 – S0281)
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)

Chapter 11
Coding Policies and Guidelines
(Optometric/Optical Services)
Table of Contents
Ophthalmological Services ..................................................................................................11-2
Charges for Lenses and Contact Lens Fitting......................................................................11-2
Eyewear billing and Reimbursement...................................................................................11-2
Routine Vision Services.......................................................................................................11-2
Vision Therapy Services...................................................................................................... 11-3
Claims Filing Requirements ...............................................................................................11-3
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (11/15/10) 11-1

Coding Policies and Guidelines (Optometric/Optical Services)
Ophthalmological
Services
Charges for Lenses and
Contact Lens Fitting
Eyewear billing and
Reimbursement
11-2
Blue Cross coding policy follows the CPT system of descriptive
terms and identifying codes for reporting medical services and
procedures performed by physicians and optometrists.
Both E/M codes and ophthalmology codes 92002, 92004, 92012,
92014, and 92015, may be appropriate to use by optometrists or
ophthalmologists. The level of E/M service or the selection of
ophthalmology codes must appropriately reflect the medical
condition, the medical necessity, the tests performed, and be
documented in the patient record. Selection of either an E/M code
or an ophthalmology code may be appropriate for routine or
medical diagnoses, and should be based on the CPT definitions of
services provided. Details of the patient encounter, as recorded on
the patient record, must meet or exceed the stated CPT
requirements to qualify for the code selected.
Blue Cross requires that all medical services be performed by the
professionals eligible and credentialed to perform the service. The
diagnosis and CPT coding must appropriately reflect the medical
condition and that the medical record reflect the medical necessity
and severity of the condition.
Submit charges for any type of lenses using Level II HCPCS
codes. Any fee for fitting and prescription of contact lenses may be
reported by submitting a CPT code from the contact lens services
section in addition to the contact lens supply code. The fee for
fitting and prescription of contact lenses may also be included in
the contact lens charge.
Eyewear claims will be paid to the member, not the provider. This
affects all of our members with the exception of Prepaid Medical
Assistance Program (PMAP) or Minnesota Care (MNCARE)
coverage.
If you bill eyewear for a member, you should bill the eyewear on a
separate claim form from the one used for the eye exam. Use your
optician’s contracting provider number or NPI when billing for the
eyewear. Your optometrist’s contracting provider number or NPI
should be submitted when billing for the eye exam. Blue Cross
requires that eye exams and eyewear claims not be billed on the
same claim form.
Routine Vision Services Blue Plus contracts allow routine vision exams without a referral.
However, if an illness or problem is discovered, treatment requires
a referral from the patient’s primary care clinic.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (11/15/10)

Vision Therapy
Services
Claims Filing
Requirements
Coding Policies and Guidelines (Optometric/Optical Services)
Blue Cross will reimburse the initial visit under 92060. Visual
therapy instruction by any method that is provided during the first
visit is included in this description. Separate billing for CPT code
92065 will not be allowed for the initial visit. Vision therapy
services involve non-surgical orthoptics, medical, or sensorymotor
re-education for patients who suffer from conditions such as
strabismus, amblyopia, exotropia, and/or esotropia.
All subsequent visits for patient evaluation and monitoring of
treatment will be billed to Blue Cross under CPT code 92065.
Office calls (99201-99215, 92002-92014) and sensorimotor exams
(92060) are not eligible for separate billing from the providers of
the visual therapy during the course of treatment unless a medical
examination is clinically indicated for other reasons.
Use CPT codes or HCPCS level II code to bill your services.
ICD-9-CM codes should be used to submit an appropriate
diagnosis for your patient. Please note the correct code for routine
vision care is V72.0 or 367.0-367.9 completed to the appropriate
fourth and fifth digits.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (11/15/10)
11-3

Chapter 11
Coding Policies and Guidelines
(Pharmacy Services)
Table of Contents
Claims Submission................................................................................................................... 11-2
Pharmacy Claims for Blue Cross Subscribers without a Pharmacy Benefit Manager ........11-2
Claims Filing Requirements ................................................................................................ 11-2
Drug Claims Submission ..................................................................................................... 11-2
Prescribing Physician’s DEA............................................................................................... 11-2
Prior Authorization .............................................................................................................. 11-3
Injectable Drugs...................................................................................................................11-3
Pharmacies Submitting Claims for DME ............................................................................ 11-3
Claim Processing...................................................................................................................... 11-4
NDC Numbers ..................................................................................................................... 11-4
Copays/Coinsurance ............................................................................................................11-4
Vacation Prescription Requests ........................................................................................... 11-4
Prescription Cost Less Than Copay..................................................................................... 11-4
Discounting or Waiving Copays..........................................................................................11-4
Pharmacy Audits.................................................................................................................. 11-4
Drugs ......................................................................................................................................... 11-5
Drug Formulary ................................................................................................................... 11-5
Drugs with a Non-preferred Status ...................................................................................... 11-6
Quantity Limits ....................................................................................................................11-7
Compounded Prescriptions ..................................................................................................11-7
Over-the-Counter Drugs ...................................................................................................... 11-7
Dispense As Written (DAW)...............................................................................................11-8
Investigative Drug Use ........................................................................................................11-8
Drug Programs......................................................................................................................... 11-9
Specialty Drugs....................................................................................................................11-9
Step Therapy Program ....................................................................................................... 11-11
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/09/11) 11-1

Coding Policies and Guidelines (Pharmacy Services)
Claims Submission
Pharmacy Claims for
Blue Cross Subscribers
without a Pharmacy
Benefit Manager
Claims Filing
Requirements
Drug Claims
Submission
Prescribing Physician’s
DEA
11-2
All pharmacies that are contracted with Blue Cross and Blue
Shield of Minnesota (Blue Cross) are required to submit
prescription charges on behalf of any Blue Cross subscriber, when
a subscriber’s contract does not use a pharmacy benefit manager.
The pharmacy should not request that the subscriber pay for any
services before claim adjudication other than the copayment
amount stated on the subscriber’s member ID card. At this time the
pharmacy claims should be submitted in a paper format. Once the
claim is received at Blue Cross, the appropriate benefits and
reimbursement will be applied according to the provider and
subscriber contracts.
The majority of our member contracts contain basic drug coverage.
Drug claims are either processed by Blue Cross or Prime
Therapeutics. To determine if a drug claim should be submitted to
Blue Cross or Prime Therapeutics for processing, check the
member’s ID card. If the member has drug processing through
Prime Therapeutics, the medical identification (ID) card will
indicate RxPCN (the carrier code) “PGIGN”. A Prime
Therapeutics provider must be used. You must include the two
digit numeric dependent code, which is indicated before the name
on the member ID card. For an example of a member ID card,
refer to bluecrossmn.com. Type in the search field “sample id
card”.
Providers within the Prime Therapeutic network must submit
claims electronically.
If the member has Prime Therapeutics coverage, but the Prime
Therapeutics information is not printed on the member ID card, the
member should pay the prescription in full and submit the claim to
Prime Therapeutics for direct reimbursement.
Submit Prime Therapeutics member drug claims to:
Prime Therapeutics
Mail Route BCBSMN
P.O. Box 14501
Lexington, KY 40512-4501
The physician’s NPI (National Provider Identifier) number must be
entered on all electronic or paper claims submitted for payment.
This information is used for drug utilization review aimed at
improving the quality of health care delivered to our members.
Leaving this data element out or use of a dummy NPI number
constitutes an incomplete pharmacy claim.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/09/11)

Coding Policies and Guidelines (Pharmacy Services)
Prior Authorization The prescribing physician must obtain prior authorization through
Blue Cross’s medical review area for certain drugs. Some
examples of drugs requiring prior authorization include infertility
drugs and growth hormones.
For a complete listing, refer to the Blue Cross and Blue Shield of
Minnesota Medical Policy Update. To view medical policies go to
providers.bluecrossmn.com and select “Medical policy” under
“Tools & Resources.”
For drugs that require a prior authorization, complete a Minnesota
Uniform Form for Prescription Drug Prior Authorization (PA)
Requests and Formulary Exceptions.
Injectable Drugs Most prescription benefit plans allow injectable processing online.
Be sure to use the appropriate NDC and submit your claim
electronically to the processor.
Pharmacies Submitting
Claims for DME
For durable medical equipment, the pharmacy must follow the
normal process for claims submission utilizing the electronic 837P
claim format.
The Aware Agreement, Article III, Section A, "Scope of Services"
states: “Provider shall provide Health Services to Subscribers for
eligible Prescription Drugs which are authorized by a valid
prescription.” This section also includes the dispensing of durable
medical equipment (DME) to Blue Cross subscribers.
It is the responsibility of the participating pharmacy to submit the
claims for all such eligible services to Blue Cross on behalf of the
subscriber. After the claim is processed by Blue Cross, you will be
notified of the proper amount to bill the subscriber, if any balance
remains due from the subscriber.
It is also the responsibility of all participating providers to abide by
all other terms and provisions of the agreement including, but not
limited to, the administration of the coordination of benefits
provisions. This process is detailed in Article III, Section M,
Coordination of Benefits.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/09/11)
11-3

Coding Policies and Guidelines (Pharmacy Services)
Claim Processing
NDC Numbers The NDC numbers submitted on the pharmacy claim must be
taken from the container from which the drug was dispensed. The
NDC number must match the manufacturer and package size.
Copays/Coinsurance The drug copay/coinsurance amount varies for each subscriber.
Rely on “claim response” to correctly identify the amount to
collect from the member. If a member’s contract contains the
formulary amendment, a dual copay may be in effect. Again, rely
on “claim response” to determine the correct amount to collect
from the member.
Vacation Prescription
Requests
Prescription Cost Less
Than Copay
Discounting or Waiving
Copays
Requests for additional drug quantities may be made by the
member, physician, or pharmacist. The member would contact the
customer service number listed on the back of their member ID
card. The physician or pharmacist would contact the pharmacy
help desk. Please keep in mind that some drugs are controlled
substances and may require a new prescription.
If the cost of the prescription is less than a member’s copay, the
member should pay the lesser of the allowed amount as shown on
the claims response.
In order to maintain the level of subscriber responsibility specified
in Blue Cross contracts, it is essential that members pay the
agreed-upon copay for preferred and non-preferred drugs. Both
member and provider agreements specifically state that the copay
must be collected in full. Noncompliance of this provision, through
discount or waiver, could result in termination of the provider
agreement.
Pharmacy Audits Blue Cross performs comprehensive pharmacy program integrity
audits to ensure compliance with its programs.
11-4
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/09/11)

Drugs
Coding Policies and Guidelines (Pharmacy Services)
Drug Formulary Blue Cross promotes the use of the member’s specified drug
formulary. The formularies have been developed to provide a
listing of drugs that are safe, effective, high-quality and
economical.
FlexRx is the standard Blue Cross drug list, which provides
our members with broad access to drugs at a reasonable overall
cost.
GenRx is a formulary option designed to maximize costeffectiveness
through the use of generic drugs. Brand drugs are
on the formulary only when a generic drug is not available to
treat a specific medical condition or when the brand drug offers
a significant advantage over generic drugs.
Definitions
Formulary is a list of preferred drugs with coverage under the
plan. This list may change during the year.
Preferred drug is a drug that is covered under the plan because
it is included on the formulary drug list.
Non-preferred drug is a drug not on the formulary drug list, but
could be covered under an open pharmacy benefit plan design.
Open pharmacy benefit plan design is a benefit design that
covers most drugs regardless of the status (preferred or nonpreferred)
on the formulary drug list. The member’s financial
responsibility will vary based on formulary status and benefit
design.
Closed pharmacy benefit plan design is a benefit design that
covers only drugs on the formulary drug list. A member can
get a non-preferred drug, but is responsible for 100% of the
cost unless a formulary exception is submitted and approved.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/09/11)
11-5

Coding Policies and Guidelines (Pharmacy Services)
Drug Formulary
(continued)
Drugs with a Nonpreferred
Status
11-6
Requesting to add a drug to the formulary
Any participating health care provider may request the addition of
a non-preferred drug to a preferred status by sending a letter to
Blue Cross. Include the following:
Name of prescribing MD
Clinic name
Clinic phone number
Clinic fax number
Name of drug
Name of manufacturer
Rationale for adding the drug
A new FDA-approved drug is not considered to be on the drug
formulary until it has been approved by the formulary committee.
To view the formularies go to providers.bluecrossmn.com, click
“More tools & resources” under “Tools & Resources”, and then
select “Formularies and drug programs”.
Physicians may request coverage of a non-preferred drug for a
member by completing the Minnesota Uniform Form for
Prescription Drug Prior Authorization (PA) Requests and
Formulary Exceptions. Member liability for non-preferred drugs is
subject to the member specific benefit design.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/09/11)

Coding Policies and Guidelines (Pharmacy Services)
Quantity Limits Certain drugs have limits on the quantity that can be given to a
patient during a period of time. Quantity limits are set to encourage
appropriate drug usage, enhance drug therapy and reduce costs.
Preferred and non-preferred drugs may have quantity limits. Check
your plan’s certificate or other materials for benefit details.
Compounded
Prescriptions
Over-the-Counter
Drugs
Drug list and request form
FlexRx quantity limit drug list (PDF) – Quantity limits for the
FlexRx formulary. The list is subject to change without notice.
GenRx quantity limit drug list (PDF) – Quantity limits for the
GenRx formulary. The list is subject to change without notice.
Quantity limits override request form (PDF) – The prescriber
must complete and submit this form to request a quantity
exception. The prescriber can also get this form by calling
provider services at (651) 662-5200 or 1-800-262-0820.
Compounded prescriptions are considered preferred drugs
provided they contain at least one federal legend drug in the final
product. Use of the compound indicator for compounded
prescriptions is reserved for prescriptions requiring the pharmacist
to combine two or more ingredients.
Many drugs a member could once only get with a prescription are
now available over the counter at a local pharmacy. These drugs
are just as safe and effective as the prescription versions. Check
the plan’s certificate of coverage or other materials for benefit
details.
What it means for the member
If the member has this benefit available, they can get an over-thecounter
drug that’s identical to the prescription version at no cost
to them, or at their plan’s lowest copay amount. The cost depends
on their plan.
How the member gets started
Check the OTC drug list to see if they’re taking a drug that
qualifies – see the OTC drug list (PDF). (The list is subject to
change without notice.)
Write the member’s prescription for the over-the-counter version
of the drug.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/09/11)
11-7

Coding Policies and Guidelines (Pharmacy Services)
Dispense As Written
(DAW)
Blue Cross provides for the payment of claims coded ‘‘dispense as
written’’ (DAW). Consistent with state law, DAW must be in the
physician’s handwriting or when an oral prescription is given,
specifically stated. Physicians may use DAW to prevent generic
substitution. Only a physician may indicate DAW on a
prescription. Neither member nor pharmacist may change this
status for any reason. A DAW may not always result in a lower
copay. This will be dependent on the patient’s benefit plan.
Investigative Drug Use Drugs used investigatively are not eligible for reimbursement.
11-8
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/09/11)

Drug Programs
Coding Policies and Guidelines (Pharmacy Services)
Specialty Drugs Specialty drugs are used to treat serious or chronic medical
conditions such as multiple sclerosis, hemophilia, hepatitis and
rheumatoid arthritis. They are typically injectable and can be selfadministered
by a patient or family member.
When a member receives their drugs from a specialty network
supplier, they are assured quality while saving money and time.
Contact provider services to verify if the member’s plan has the
specialty drug program as an available benefit.
Quality
The specialty network suppliers are accredited by the Joint
Commission on Accreditation of Healthcare Organizations, which
ensures the highest standard of pharmacy care. They’re experts in
supplying drugs and services to patients with complex health
conditions.
Convenience
The member can order their specialty drug each month from a
specialty drug supplier, pay their health plan’s applicable innetwork
copay or coinsurance amount and eliminate the expense
of driving or having to find transportation to a pharmacy to pick up
their drugs.
Specialty Drug List
The Specialty Drug List is available on bluecrossmn.com.
Other prescription drugs
Only select injectable and oral drugs are available through the
specialty drug program. Members will need to continue to get their
other prescription drugs through their local pharmacy.
More information
Additional information is available on bluecrossmn.com in
regards to the specialty drug network.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/09/11)
11-9

Coding Policies and Guidelines (Pharmacy Services)
Specialty Drugs
(continued)
11-10
Specialty Network Suppliers
The specialty drug benefit program offers you these choices in
professional specialty drug suppliers:
Fairview Specialty Pharmacy, LLC*
1-800-595-7140
(612) 672-5262 (Fax)
www.fairviewspecialtyrx.org
*Fairview can only fill prescriptions for hemophilia, growth
hormone infertility and oral chemotherapy drugs.
Triessent
1-888-216-6710
1-866-203-6010 fax
The specialty network suppliers were selected for their outstanding
customer service and dedication to patients. These suppliers are
experts in handling the types of drugs you’re taking.
Prime Therapeutics, LLC is an independent company providing
pharmacy benefit management services.
Fairview Specialty Pharmacy, LLC is an independent company
providing pharmacy benefit management services.
Triessent, provided by Prime Therapeutics, a specialty pharmacy
program, is an independent specialty pharmacy program.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/09/11)

Coding Policies and Guidelines (Pharmacy Services)
Step Therapy Program A step therapy program is an approach to providing drug coverage.
It encourages the use of cost-effective prescription drugs, when
appropriate. This means that the member may first need to try an
alternative drug, typically a generic drug, before we will cover
certain drugs prescribed by your doctor. Step therapy programs are
developed using treatment guidelines, clinical evidence and
research. Check the member’s plan’s certificate of coverage or
other materials for benefit details.
What it means for the member or patient
If the member is currently taking a drug that’s included in our step
therapy program, please talk to your patient. Together you can
discuss which drug options are best for the patient. You can decide
whether to write a new prescription or submit a written request for
the member to remain on his/her current drug.
Drug lists and authorization form
GenRx Step Therapy program - drug list (PDF) – All users of
the GenRx formulary have step therapy. The list is subject to
change without notice.
FlexRx Step Therapy program - drug list (PDF) – Step therapy
programs for the FlexRx formulary vary based on employer
group. The list is subject to change without notice.
Step Therapy authorization form (PDF) – Your doctor must
complete and submit this form to request an exception to this
program. Your doctor can also get this form by calling
provider services at (651) 662-5200 or 1-800-262-0820.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/09/11)
11-11

Chapter 11
Coding Policies and Guidelines
(Public Programs)
Table of Contents
Child and Teen Checkups ....................................................................................................11-2
S0302 ................................................................................................................................... 11-4
C&TC Referral Codes..........................................................................................................11-4
Public Health Nursing Services ........................................................................................... 11-5
Interpretive Services ............................................................................................................ 11-6
Blue Plus Contracted Interpreter Agencies.......................................................................... 11-9
Community Health Workers.............................................................................................. 11-13
Newborn Circumcision ...................................................................................................... 11-14
Hearing Aid Fee Schedule Update..................................................................................... 11-15
GenRx Formulary ..............................................................................................................11-16
Formulary Exception Process ............................................................................................ 11-17
PCA Billing........................................................................................................................11-19
PCA Billing (continued) ....................................................................................................11-20
Chiropractic, Physical, Occupational, and Speech Therapy Authorization.......................11-21
Services to Restricted Recipients....................................................................................... 11-24
MHCP Changes in Prior Authorization .............................................................................11-26
Special Transportation ....................................................................................................... 11-29
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (02/07/12) 11-1

Coding Policies and Guidelines (Public Programs)
Child and Teen
Checkups
Child and teen checkups (C&TC) are comprehensive preventive
care services provided to children under the age of 21 enrolled in a
public program. These services are usually performed at the
primary care clinic (PCC). They may also be performed by a
public health nurse clinic in the referral network without a referral
from the PCC.
Child and teen checkups can be identified by procedure code
S0302 on a claim or on another claim with the same date of
service. Since these checkups involve additional time spent with
the patient, this code allows the provider to charge a “bump-up”
amount for performing the C&TC.
Covered Services
Anticipatory guidance and health education
Assessment of physical growth and measurements
Health history including mental health, nutrition, and chemical
use
Developmental/behavioral assessments
Physical examination including sexual development, oral exam
Immunizations/review
Laboratory tests including blood lead, urinalysis,
hemoglobin/hematocrit and other tests as indicated
Vision screening
Hearing screening
Dental checkups - verbal referral for preventive dental care
Diagnosis and treatment of health conditions listed in the
Minnesota Health Care Programs (MHCP) benefit plan and
others determined to be medically necessary, are also covered
services.
C&TC Component Commonly Billed Code(s) Notes
Anticipatory
Guidance and health
education
Measurement –
height, weight, head
circumference, blood
pressure
11-2
99401-99404 This component may be billed separately
only if at least 15 minutes is spent
specifically on this topic.
Not billed separately, part
of the E&M
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (02/07/12)

C&TC Component Commonly Billed Code(s) Notes
Health History Not billed separately, part
of the E&M
Developmental /
Behavioral
Physical – including
sexual development
and oral exam
Immunizations /
Vaccines
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (02/07/12)
Coding Policies and Guidelines (Public Programs)
96110 or 96111 This code may be billed if a measurable
tool is used to assess the developmental
and behavioral level of the child.
99381-99385 or 99391-
99395
90460, 90461, 90470,
90471, 90472, 90473,
90474
Appropriate
vaccine/toxoid code with
an –SL modifier (if the
immunization is available
through the Minnesota
Vaccines for Children
program).
Laboratory Tests Billed as appropriate
Bill developmental and mental health
screenings using:
96110 for an objective, standardized
developmental screening instrument
96110-UC for a standardized mental
health screening instrument
This code is billed according to whether
the child is a new or established patient
and the age of the child.
Administration is billed with the
appropriate administration code(s).
Immunizations are billed with the
appropriate vaccine code appended with
an –SL modifier to indicate the vaccine
was obtained free through the Minnesota
Vaccines for Children program.
All providers must use the available free
vaccines for MHCP covered children.
Blood Lead 83655 Blood lead screening is a required
component at 12 & 24 months of age, but
can occur at other times within these
ranges if necessary. Lead testing is a
federally required component of C&TC.
Vision 99173 This code may be billed for children three
years of age and older to indicate that an
objective screening was performed.
Hearing V5008 or 92551 This code may be billed for children three
years of age and older to indicate that an
objective screening was performed.
11-3

Coding Policies and Guidelines (Public Programs)
C&TC Component Commonly Billed Code(s) Notes
Dental Checkups-
verbal referral
Fluoride Varnish
Application
11-4
Not billed separately, part
of the E/M
Dental services processed through Delta
Dental of Minnesota.
D1206 Billed by PCC or Public Health Nursing
Clinic and paid as part of the C&TC.
Eligible providers include:
Nurse practitioners
Nurses
Physicians
Physician Assistants
Staff under the supervision of the treating
physician
S0302 If HCPCS code S0302 is submitted on a claim for any member
other than an MHCP member, it will be denied as provider
liability. Code S0302, completed early periodic screening
diagnosis and treatment service (EPSDT) (list in addition to code
for appropriate evaluation and management service), should be
submitted only when a completed well child or child and teen
checkup is performed for an MHCP member (i.e., PMAP or
MNCare).
C&TC Referral Codes The C&TC referral codes must be submitted on C&TC claims to
inform state and county C&TC staff that a referral was made.
Follow-up assistance is provided by the state and county to help
assure follow-up care is received. The C&TC referral codes also
fulfill Minnesota’s reporting requirements to the Centers for
Medicare and Medicaid Services (CMS) for the number of
referrals made as a result of C&TC screenings.
The C&TC referral code pertains to the entire claim and must be
entered as value '01' in loop 2300, CLM12 on the 837P claim. It
documents that a complete C&TC screening was performed for
enhanced/appropriate reimbursement purposes.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (02/07/12)

Public Health Nursing
Services
Coding Policies and Guidelines (Public Programs)
The following services may be billed by Public Health on a
professional claim (837P). These services are eligible under the
Public Nursing Clinic (PHNC) contract without a referral from the
member’s primary care clinic or a prior authorization from Blue
Plus (these services are found in Chapter 8 of the MHCP manual.
If a service requires a physician’s order and can be billed to
Medicare or other third party payers, those services are not billable
by Public Health.
In addition, Public Health may bill for Enhanced Services for “At-
Risk” Pregnancies, as well as patient education services found in
Chapter 10 of the MHCP manual.
Codes Description
H1002 Care coordination
H1003 Prenatal health education I
Prenatal health education II
Prenatal nutrition education services
H1004 Postpartum follow-up home visit
S9445 Patient education, not otherwise classified, nonphysician
provider, individual, per session
S9446 Patient education, not otherwise classified, nonphysician
provider, group, per session
S9442 Birthing classes, non-physician provider, per session
S9443 Lactation classes, non-physician provider, per session
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (02/07/12)
11-5

Coding Policies and Guidelines (Public Programs)
Interpretive Services Blue Plus contracts with several interpreter agencies to provide
sign and spoken interpreter services for members of Blue Plus
MHCP plans only.
11-6
These members can be identified by their identification numbers,
which begin with “80” (i.e. 80XXXXXXX).
Primary care clinics, physician specialty clinics and Select
behavioral health clinics may request a contract in order to provide
and bill Blue Plus for interpreter services at their sites for MHCP
members. To request a contract, primary care clinics, physician
specialty clinics or Select behavioral health clinics should fax a
request to Theresa Peters-Nelson, Provider Contracting at
(651) 662-6326, or mail your request to:
Blue Cross and Blue Shield of Minnesota
Attn: Theresa Peters-Nelson, S117
1750 Yankee Doodle Road
Eagan, MN 55121-1600
Effective January 1, 2011, in order to comply with Minnesota
Department of Human Services requirements (in accordance with
Minnesota State Statute Sec. 144.058), any interpretation services
provided to Blue Plus Minnesota Health Care Program members
must be rendered by a registered and rostered interpreter with
proper certification.
All providers contracted with Blue Plus for provision of
interpretation services are accountable for ensuring that
interpreters employed by or contracted with their agency meet
these requirements.
Services provided by interpreters who do not meet the
qualifications outlined in the statute are ineligible for payment and
should not be billed to Blue Plus. Interpreters who are not properly
qualified cannot bill either Blue Plus or the member.
If the provider does not have a Blue Plus interpreter contract and
schedules interpreter services with an interpretation agency that
does not hold a contract with Blue Plus Public Programs customer
service, the interpreter charges are the financial responsibility of
the provider. Hospitals are responsible for arranging and
reimbursing for interpreter services for hospital inpatient services.
A Blue Plus Public Programs member, clinic, public health agency
or county worker may call Blue Plus Public Programs Customer
Service, or the contracted interpreter agency for assistance in
scheduling an interpreter for the member’s covered health services.
The contracted agency will bill Blue Plus directly.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (02/07/12)

Interpretive Services
(continued)
Billing Guides
Coding Policies and Guidelines (Public Programs)
The following guides for reporting interpreter services have been
approved by the MN Administrative Uniform Committee and are
listed in the MINNESOTA UNIFORM COMPANION GUIDE
FOR IMPLEMENTATION OF THE ASC X12/005010X222.
HEALTH CARE CLAIM: PROFESSIONAL (837).
Note: Rounding rules apply to all services below. A minimum of
eight minutes must be spent in order to report one unit.
T1013 -- Face-to-face oral language interpreter services per 15
minutes
T1013-U3 -- Face-to-face sign language interpreter services per 15
minutes
T1013-GT -- Telemedicine interpreter services per 15 minutes
T1013-U4 -- Telephone interpreter services per 15 minutes
T1013-UN, UP, UQ, UR, US Interpreter services provided to
multiple patients in a group setting
T1013-52 -- Interpreter drive time, wait time, no show/cancellation
per 15 minutes
Report one unit per 15 minutes per client
For multiple encounters with the same patient on the same
day, report one line with units reflecting total time with
patient
If more than one type of service is provided, report each on
a separate line appended with the -59 modifier; for
example:
T1013-52 x 2 units (30 minutes of drive time)
T1013-5259 (12 minutes of wait time)
Add narrative(s) in the NTE segment to report the service(s)
rendered. An NTE segment is required for each line.
Reporting drive time versus mileage is based on individual
contract. T1013-52 may not be used for drive time if mileage
(see 99199) is reported
A canceled service may be reported only if the interpreter has
already arrived for the appointment prior to the cancellation
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (02/07/12)
11-7

Coding Policies and Guidelines (Public Programs)
Interpretive Services
(continued)
11-8
99199 -- Mileage for interpreter service
Reporting mileage versus drive time is based on individual
contract. 99199 may not be used if drive time (T1013-52) is
reported
Report one unit per mile
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (02/07/12)

Blue Plus Contracted Interpreter Agencies
Coding Policies and Guidelines (Public Programs)
Provider Languages Geographic Coverage (By County)
Kim Tong
Phone #:
(612) 724-5962
Midwest Language Banc
Phone #:
(612) 695-6008
Afar, Albanian, American Sign
Language, Amharic, Anuak, Arabic,
Armenian, Belarusian, Berber,
Bosnian, Bulgarian, Burmese,
Cambodian, Cantonese, Creole,
Croatian, Farsi, Filipino, French,
German, Gujarati, Hebrew, Hindi,
Hmong, Indonesian, Italian, Japanese,
Karen, Korean, Krahn, Kurdish,
Laotian, Lithuanian, Macedonian,
Mandarin, Nepalese, Oromo, Persian,
Polish, Portuguese, Punjabi,
Romanian, Russian, Serbian, Somali,
Spanish, Swahili, Taishanese, Thai,
Tibetan, Tigrinia, Turkish, Ukrainian,
Urdu, Vietnamese, Yiddish
Sign Language—YES
Akkan, Albanian, American Sign
Language (Metro Area Only),
Amharic, Arabic, Armenian, Bashto,
Bassah, Bayer, Belrussian, Bengali,
Burmese, Bhutan, Bosnian, Bulgarian,
Cambodian, Cantonese, Chinese,
Comoren, Creole, Croatian, Cubano,
Dari, Dinka, Ethiopian, Eritrean, Farsi,
Filipino, French, French Krio, Gbanti,
German, Gio, Greek, Gujarati, Hausa,
Hebrew, Hindi, Hmong, Indonesian,
Ibo, Irani, Italian, Japanese, Katchi,
Kissi, Kiswahili, Korean, Kpelleh,
Krahn, Kru, Kurdish, Laotian,
Lingala, Lorma, Luganda, Mandarin,
Mandingo, Mano, Micronesian,
Nepali, Nuer, Oromo, Pashto, Persian,
Pigeon-English, Polish, Portuguese,
Punjabi, Romanian, Russian,
Shanghiese, Sierra Leone, Somali,
Spanish, Swahili, Tagalog ,
Taiwanese, Tamil, Tajik Telugu,
Telegis, Telegu, Temne, Thai,
Thirumalai, Tibetan, Tigrinya, Tomi,
Turkish, Ukrainian, Urdu,
Vietnamese, Wolaff, Yoruba
Sign Language—YES (Metro Area
Only)
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (02/07/12)
Becker, Brown, Chisago, Clay,
Cottonwood, Dakota, Dodge,
Faribault, Fillmore, Freeborn,
Goodhue, Hennepin, Isanti, Jackson,
Kandiyohi, Le Sueur, Lyon, Martin,
Meeker, Mower, Murray, Nicollet,
Nobles, Olmsted, Otter Tail,
Pipestone, Ramsey, Redwood,
Renville, Rice, Rock, Scott,
Sherburne, Sioux Falls (South
Dakota), Stearns, Steele, Wabasha,
Waseca, Washington, Watonwan,
Wilkin, Winona, Wright
Aitkin, Anoka, Becker, Beltrami,
Benton, Big Stone, Blue Earth,
Brown, Carlton, Carver, Cass,
Chippewa, Chisago, Clay, Clearwater,
Cook, Cottonwood, Crow Wing,
Dakota, Dodge, Douglas, Faribault,
Fillmore, Freeborn, Goodhue, Grant,
Hennepin, Houston, Hubbard, Isanti,
Itasca, Jackson, Kanabec, Kandiyohi,
Kittson, Koochiching, Lac qui Parle,
Lake, Lake of the Woods, Le Sueur,
Lincoln, Lyon, Mahnomen, Marshall,
Martin, McLeod, Meeker, Mille Lacs,
Morrison, Mower, Murray, Nicollet,
Nobles, Norman, Olmsted, Otter Tail,
Pennington, Pine, Pipestone, Polk,
Pope, Ramsey, Red Lake, Redwood,
Renville, Rice, Rock, Roseau, Scott,
Sherburne, Sibley, St Louis, Stearns,
Steele, Stevens, Swift, Todd, Traverse,
Wabasha, Wadena, Waseca,
Washington, Watonwan, Wilkin,
Winona, Wright, Yellow Medicine
11-9

Coding Policies and Guidelines (Public Programs)
Provider Languages Geographic Coverage (By County)
Project FINE
Phone #:
(507) 452-4100
ARCH Language Network
Phone #:
(651) 789-7897
The Bridge
Phone #:
(320) 259-9239
11-10
Arabic, Bosnian, Bulgarian,
Cambodian, Chinese, Dinka, French,
German, Hmong, Italian, Japanese,
Korean, Laotian, Nepali Portuguese,
Romanian, Russian, Somali, Spanish,
Swahili, Thai, Tibetan, Vietnamese
Sign Language—NO
Afar, Albanian, Amharic, Anuak,
Arabic, Armenian, Belarusian, Berber,
Bhutanese, Burmese, Bosnian,
Cambodian, Cantonese, Creole,
Croatian, Dioula, Eritrean, Farsi,
French, Gujarati, Hindi, Hmong, Igbo,
Italian, Japanese, Karen, Korean,
Laotian, Malinke, Mandarin, Nepali,
Nuer, Oromo, Pashto, Persian,
Portuguese, Punjabi, Romanian,
Russian, Serbian, Somali, Spanish,
Swahili, Thai, Tigrinya, Turkish,
Ukrainian, Urdu, Vietnamese, Yoruba
Sign Language—NO
American Sign Language, Arabic,
Bangladeshi, Bengali, Bosnian,
Bulgarian, Chinese, French, German,
Gujarati, Hindi, Hmong, Kurdish,
Laotian, Malay, Marathi, Nuer,
Oromo, Portuguese, Punjabi, Pushto,
Romanian, Russian, Serbian, Serbo-
Croatian, Somali, Spanish, Swahili,
Tagalog, Thai, Tigrinya, Ukrainian,
Urdu, Vietnamese
Sign Language--YES
Winona
Anoka, Benton, Blue Earth, Carver,
Carver, Chisago, Clay, Dakota,
Faribault, Hennepin, Isanti, Jackson,
Kandiyohi, Le Sueur, Lincoln, Lyon,
McLeod, Meeker, Mille Lacs,
Mower, Nicollet, Nobles, Norman,
Olmsted, Polk, Ramsey, Red Lake,
Rice, Scott, Sherburne, Sibley, St
Louis, Stearns, Steele, Wabasha,
Waseca, Washington, Winona,
Wright
Anoka, Benton, Carver, Clay, Crow
Wing, Dakota, Hennepin, Isanti, Lyon,
Olmsted (Spanish only), Ramsey,
Redwood, Rice, Scott, Sherburne,
Stearns, Stevens (Spanish only),
Washington, Wright
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (02/07/12)

Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (02/07/12)
Coding Policies and Guidelines (Public Programs)
Provider Languages Geographic Coverage (By County)
Garden and Associates
Phone #:
(952) 920-6160
Afar, Afghan, Akan, Albanian,
Amharic, Anuak, Arabic, Aramaic,
Armenian, Ashante, Asturian, Azeri,
Bahasa, Bana, Bandi, Bari, Basque,
Bassa, Belarusian, Bengali, Berber,
Bosnian, Breton, Bulgarian, Burmese,
Cambodian, Cantonese, Catalan,
Cherokee, Chinese, Coniagui, Creole,
Croatian, Czech, Dagaare, Dan,
Danish, Dari, Dibo, Dinka, Dutch,
Dzongkha, Egyptian, English,
Esperanto, Estonian, Ethiopian, Ewe,
Fanti, Farsi, Finnish, French, Frisian,
Fulani, Ga, Gaelic, Galego, Gbandi,
Georgian, German, Gio, Grebo,
Greek, Gujarati, Guyanese, Haitian
Creole, Hausa, Hawaiian, Hebrew,
Hindi, Hmong, Hungarian, Ibo/Igbo,
Icelandic, Indonesian, Inuit, Irish,
Italian, Japanese, Javanese, Kannada,
Karen, Kazakh, Khmer, Kirghizian,
Kissi, Kona, Korean, Kpelle, Krahn,
Krio, Kru, Kuku, Kurdish, Laotian,
Latin, Latvian, Liberian, Lingala,
Lithuanian, Lorma, Luganda,
Macedonian, Maide, Malagasy,
Malayalam, Malinke, Maltese,
Mandarin, Mandingo, Mano, Marathi,
Marshallese, Mazahua, Mende, Mina,
Moldovian, Mongolian, Navajo,
Nepali, Norwegian, Nuer, Ogoni,
Ojibwa, Oromo, Pashto, Persian,
Polish, Portuguese, Quechua, Quiche,
Romani, Romanian, Romansch,
Rundi, Russian, Samoan, Sarpo,
Senegalese, Serbian, Shanghainese,
Sinhala, Slovak, Slovenian, Somali,
Sotho, Spanish, Sudanese,
Susu/Soussou, Swahili, Tagalog,
Taishanese, Taiwanese, Tamil,
Telugu, Thai, Tibetan, Tigrinya,
Tswana, Turkish, Turkmen, Twi,
Ukrainian, Urdu, Uzbek, Vai,
Vietnamese, Welsh, Wolof, Yao,
Yiddish, Yoruba, Zulu
Sign Language—NO
Anoka, Beltrami, Benton, Blue Earth,
Carlton, Carver, Chisago, Crow Wing,
Dakota, Dodge, Douglas, Faribault,
Fillmore, Freeborn, Goodhue,
Hennepin, Huston, Isanti, Itasca,
Jackson, Kandiyohi, Lac qui Parle, Le
Sueur, Marshall, Meeker, McLeod,
Mille Lacs, Morrison, Mower,
Nicollet, Nobles, Olmsted, Pine,
Pipestone, Ramsey, Rice, Scott,
Sherburne, St. Louis, Stearns, Steele,
Todd, Traverse, Wabasha, Waseca,
Washington, Watonwan, Winona,
Wright
11-11

Coding Policies and Guidelines (Public Programs)
Provider Languages Geographic Coverage (By County)
A-Z Friendly Languages
Phone #:
(763) 566-4312
Intercultural Mutual
Assistance Association
(IMAA)
Phone #:
(507) 289-5960
11-12
Afar, Albanian, Amharic, Arabic,
Armenian, Azerbaijani, Basa,
Belarusian, Bengali, Bosnian (Serbo-
Croatian), Bulgarian, Burmese,
Cebuano, Chinese (Cantonese,
Mandarin, Toysanese), Czech, Danish,
Dutch, Erithrian, Estonian, Ewe, Farsi,
Finnish, French, Gbandi, Geo,
Georgian, German, Grebo, Greek,
Gujarathi, Haitian Creo, Hebrew,
Hindi, Hmong, Hungarian, Idbo,
Indonesian, Italian, Japanese, Kazakh,
Khmer, Kirghiz, Kisi, Korean, Kpelle,
Krahn, Krio, Kru, Kurdish, Latvian,
Laotian, Lebanese, Liberian English,
Lithuanian, Lorma, Luganda,
Mandingo, Mano, Moldovan,
Mongolian, Norwegian, Oromo,
Polish, Portuguese, Punjabi, Pushtu,
Romanian, Russian, Sarpo, Slovak,
Slovenian, Somali, Soninke, Spanish,
Susu, Swahili, Swedish, Tadzik,
Tagalog, Tatar, Telugu, Tibetan,
Tigrinya, Turkish, Turkmen, Twi,
Ukranian, Urdu, Uzbek, Vietnamese,
Yoruba
Sign Language—NO
American Sign Language, Amharic,
Anuak, Arabic, ASL, Bari, Bosnian,
Burmese, Cantonese, Creole, Czech,
Dinka, Farsi, Filipino, French,
German, Grebo, Greek, Hindi,
Hmong, Homala, Indonesian, Italian,
Japanese, Kamba, Kiswahili, Khmer,
Korean, Krio, Kurdish, Lango, Lahu,
Lao, Lao-lu, Lao-Tinh, Lokoya,
Lopit, Lotoko, Luo, Mai, Mandarin,
Mendi, Nuer, Oromo, Pakistani,
Polish, Portuguese, Punjabai,
Quechua, Romanian, Russian,
Somali, Spanish, Swahili, Tagalog,
Temne, Tigrinia, Thai, Turkish, Urdu,
Vietnamese
Sign Language---YES
Anoka, Carver, Chisago, Dakota,
Goodhue, Hennepin, Isanti,
Kandiyohi, Le Sueur, McLeod,
Mower, Olmsted, Polk, Ramsey, Rice,
Scott, Sherburne, Sibley, Stearns,
Washington, Wright
Blue Earth, Dodge, Faribault,
Fillmore, Freeborn, Goodhue,
Houston, Mower, Olmsted, Rice,
Steel, Wabasha, Waseca, Winona
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (02/07/12)

Community Health
Workers
Coding Policies and Guidelines (Public Programs)
Blue Plus may reimburse for certain educational services provided
by Community Health Workers (CHWs).
Practitioner Enrollment Process
A CHW must meet Minnesota Department of Human Services
(DHS) eligibility requirements, and be enrolled through DHS
before requesting enrollment with Blue Plus. DHS requirements
are outlined in the MHCP Manual, which can be found at
www.dhs.state.mn.us.
Upon receiving a Unique Minnesota Provider Identifier (UMPI)
number from DHS, a CHW may then request to be registered with
Blue Plus. This process may be initiated by completing the
Individual Practitioner Addition and Termination Form, which can
be accessed at bluecrossmn.com. The CHW must be registered
with Blue Plus before services can be billed.
Member and Service Eligibility
Members enrolled in the following Blue Plus plans will have
benefits for services rendered by a CHW:
Blue Plus Plan Alpha Prefix
Blue Advantage (PMAP/GAMC) XZG
MinnesotaCare XZG
Minnesota Senior Care XZG
Minnesota Senior Care + XZG
SecureBlue SM (HMO SNP) XZS
CareBlue SM (HMO SNP) XZS
In order to be considered eligible for reimbursement, educational
services provided by a CHW must be rendered face to face in a
clinic, outpatient or home setting and be related to a medical
diagnosis. In addition, the services must be supervised by a Blue
Cross and Blue Shield of Minnesota or Blue Plus eligible
physician, dentist, public health nurse, mental health professional,
or advanced practice registered nurse (APRN).
Reference the MHCP Provider Manual for additional information
regarding requirements for physician orders/care plans, medical
record documentation, record keeping and curriculum as they
relate to CHWs. This communication can be found at
www.dhs.state.mn.us.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (02/07/12)
11-13

Coding Policies and Guidelines (Public Programs)
Community Health
Workers
(continued)
Billing
CHW services should be billed to Blue Plus as follows:
Claims format: Professional (837P)
Codes: 98960, 98961, 98962 or D1206
Provider Number: Enter the Blue Plus individual provider
number or UMPI number of the CHW on each service line
Diagnosis: Enter a valid ICD-9-CM diagnosis(es) on the claim
and link to the appropriate service line
Reimbursement
Blue Plus will utilize our standard public programs pricing
methodology for reimbursement of CHW services.
Newborn Circumcision For members of MCHP, claims payment for newborn circumcision
is the responsibility of Blue Plus. Circumcision coverage is limited
to only those procedures that are medically necessary (a pathologic
condition exists that requires circumcision). This limitation applies
to circumcision for all ages. The newborn circumcision exception
for religious practice was eliminated.
11-14
A prior authorization will be required for all circumcisions for
determination of medical necessity.
Member Eligibility
This legislative change in circumcision benefits and claims
processing applies to members in all MHCP products:
MHCP Product Name Group Number
Begins With
Blue Plus: Blue Advantage
(PMAP, & MCS+)
PP01, PP02, PP03,
PP04, PP05, PP06,
PP07, PP08, PP09
Members
Alpha Prefix
XZG
Blue Plus: MinnesotaCare PP1 XZG
Blue Plus: SecureBlue PP3 XZS
Blue Plus: CareBlue PP3 XZS
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (02/07/12)

Hearing Aid Fee
Schedule Update
Coding Policies and Guidelines (Public Programs)
Blue Plus uses the MHCP Hearing Aid Volume Purchase Contract
(which contains the MHCP Hearing Aid Contract) as the base
Medical Assistance Fee Schedule. Blue Plus will follow the noncovered
code list contained in the MHCP Hearing Aid Contract
and the DHS supply limits.
Products Affected
The following MHCP products are affected:
Blue Advantage (PMAP/GAMC, MSC & MSC+)
MinnesotaCare
CareBlue
SecureBlue
MHCP Hearing Aid Volume Purchase Contract
The hearing aid service provider must dispense the hearing aid
according to the hearing aid exam, selection and prescription of the
otolaryngologist and audiologist.
For accurate claims processing, the provider will need to submit an
attachment that includes the manufacturers’ specifications.
Providers should utilize the information contained in the current
MHCP contracts, including manufacturer, model name and model
number. This information will need to be included in the
attachment when the claim for reimbursement is submitted. Blue
Plus will verify that the hearing aid billed is a covered benefit for
the member and will apply the current MHCP Hearing Aid
Volume Purchase Contract pricing for reimbursement. Items not
included in this pricing will defer to the DHS Medical Assistance
standard fee schedule or the Blue Plus standard fee schedule, as
applicable.
Website
The current MHCP Contract Pricing can be found at:
http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DY
NAMIC_CONVERSION&RevisionSelectionMethod=LatestRe
leased&dDocName=id_010724
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (02/07/12)
11-15

Coding Policies and Guidelines (Public Programs)
Hearing Aid Fee
Schedule Update
(continued)
Prior Authorization
If the member requires a hearing aid that is not listed on the DHS
Volume Hearing Aid Purchase Contract, a prior authorization may
be submitted for review of coverage to the Prior Authorization fax
line at (651) 662-2810. Please include the following information in
the request:
Audiologic recommendations, including:
Written recommendations for hearing aid(s), including the
manufacturer specifications
Follow-up plan for determining the effectiveness of the hearing
aid
Audiogram or reason why this was not obtained
History of previous hearing aid use
Pure tone average
Reason why a standard hearing aid on the Volume Hearing Aid
Purchase Contract is not appropriate for this member
GenRx Formulary The drug formulary GenRx will apply for members covered under
Minnesota Health Care Programs.
This new formulary offers drugs that have been shown to be safe
and effective, while being cost conscious. The GenRx formulary
consists of almost all generics, with the exception of a few
generics that were not included on the new formulary due to safety
or efficacy concerns. A limited number of brand-name drugs will
be on formulary to provide appropriate coverage of most disease
states.
11-16
What does this mean for you?
You may need to prescribe a different drug that treats the same
symptoms or condition to an MHCP member. Please be aware that
most of our SecureBlue and CareBlue members have a Medicare
Part D formulary and will not be affected.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (02/07/12)

GenRx Formulary
(continued)
Formulary Exception
Process
What steps should you take?
Coding Policies and Guidelines (Public Programs)
Determine which of your patients' current prescription drugs will
not be on the GenRx drug list. To determine which drugs are on
the new GenRx formulary, visit bluecrossmn.com to view the list
of drugs available to MHCP members. Under the orange
“Resources” tab, choose “prescription drugs.” Then click on
“Search the drug lists.” When the pop-up window appears, choose
the GenRx drug list.
What if a member tries to fill a prescription for a drug not
listed in the new formulary?
The prescription will not be filled by the pharmacy. The member
will be referred back to the prescribing physician for a new
prescription.
Dispense as Written (DAW) will not process at point of sale until a
formulary exception has been received.
Anti-psychotic drugs
For anti-psychotic drugs prescribed to treat a diagnosed mental
illness or emotional disturbance that are not on the GenRx
formulary, the health care provider prescribing the drug must
certify the following to Blue Cross in writing:
1. The provider has considered all equivalent drugs on the
formulary and has determined that the drug prescribed will best
treat the patient’s condition
2. The drug must be dispensed as written (DAW)
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (02/07/12)
11-17

Coding Policies and Guidelines (Public Programs)
Formulary Exception
Process
(continued)
11-18
All other Drugs
For all other drugs not on the GenRx formulary, the health care
provider prescribing the drug must follow formulary exception
procedures to request an exception. The health care provider
prescribing the drug must do one of the following:
1. attest that the formulary drug causes an adverse reaction in the
patient
2. attest that the formulary drug is contraindicated for the patient
3. attest that the patient has tried and failed at least three (or as
many as available, if fewer than three) formulary alternatives
for the diagnosis being treated with the requested medication
4. demonstrate in writing to Blue Cross that the provider has
considered all equivalent drugs on the formulary and has
determined that the drug prescribed will best treat the patient’s
condition
The prescriber may be required to submit medical records that
support the medical necessity for the prescribed non-formulary
drug.
DAW for non-formulary drugs
Prescriptions entered with a DAW for non-formulary drugs will
not process at the point of sale until the prescriber has also
completed the second part of the process. Members will be
directed to work with their provider to determine if a formulary
drug may work for them. If the provider determines that the nonformulary
drug will best treat the member’s condition, a formulary
exception request must be submitted on the member’s behalf.
What does this mean for you?
Prescriptions written as DAW will not process at point of sale until
the certification or demonstration has been received. Members will
be directed to contact their provider to determine if a formulary
drug may work for them. If the provider determines that the nonformulary
drug will best treat the member’s condition, a formulary
exception request must be submitted on the member’s behalf.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (02/07/12)

Formulary Exception
Process
(continued)
What steps should you take?
Coding Policies and Guidelines (Public Programs)
Determine which of your patients' current prescription drugs
written as DAW are not on the GenRx drug list. To determine
which drugs are on the GenRx formulary, visit
providers.bluecrossmn.com to view the list of drugs available to
Minnesota Health Care Programs members. Under the “Tools &
Resources” tab, choose “formulary and special program drug
lists.” Then click on “see the lists” under “Blue Cross formularies”
and select “GenRx.
What if a member tries to fill a DAW prescription for a drug
not listed in GenRx?
The prescription will not be filled by the pharmacy until the
certification or demonstration has been received and approved.
The member will be referred back to the prescribing physician for
a new prescription and/or a formulary exception submission on
their behalf.
Glucose Testing Meters The new GenRx drug formulary for MHCP members will include
only the Bayer CONTOUR and BREEZE 2 glucose testing meters
and strips. All other meters and test strips will be removed from
the drug list.
We are committed to helping you make this change and serving
these members' health care needs. If the patient and doctor can
show that a glucose meter other than the Bayer CONTOUR or
BREEZE is the best option for a member's treatment, the provider
can ask Blue Plus for a formulary exception. For assistance with
this, a member can call the member services number on the back
of the member ID card.
PCA Billing Claims for PCA services must be submitted to Blue Plus using one
date of service per claim line. Any claim lines that are submitted
with more than one date of service will be denied for improper
format. All claim lines should have an individual PCA associated
with the service.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (02/07/12)
11-19

Coding Policies and Guidelines (Public Programs)
PCA Billing
(continued)
11-20
Individual PCA Enrollment
Individual PCA enrollment forms submitted with incomplete
information will be sent back to the provider unprocessed along
with a letter requesting the missing information. Upon receipt of a
complete form, the form will be processed and, if appropriate, the
individual will be affiliated with the agency. Blue Cross will
require individuals to submit their assigned UMPI number on the
enrollment form. Blue Cross will not enroll an individual PCA that
submits a copy of the completed background study in lieu of an
UMPI number.
Minnesota Health Care Programs
Group numbers for members that have coverage with MHCP are
as follows:
Product Name Group Product Group Numbers
Blue Advantage (PMAP) PP011, PP012, PP014, PP015, PP016,
PP017, PP021, PP022, PP024, PP025,
PP026, PP027, PP031, PP032,PP034,
PP035, PP036, PP037
MinnesotaCare Expanded PP111, PP112, PP151, PP152
Minnesota Senior Care
Plus (MSC+)
PP055, PP056, PP057, PP061, PP062,
PP064, PP071, PP072, PP074, PP075,
PP076, PP077
SecureBlue All group numbers that begin with
PP2
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (02/07/12)

Chiropractic, Physical,
Occupational, and
Speech Therapy
Authorization
Coding Policies and Guidelines (Public Programs)
Effective January 15, 2011, all of the following services provided
to MHCP members will require pre-authorization by Blue Plus:
Chiropractic services beyond 12 visits per calendar year
Physical therapy visits beyond 40 visits per calendar year
Occupational therapy visits beyond 40 per calendar year
Speech therapy visits beyond 50 per calendar year
These changes are consistent with changes in Minnesota statute
regarding chiropractic and therapy services for MHCP members.
Commercial lines of business are not impacted by this change.
Minnesota Health Care Programs
Group numbers for the affected products are as follows:
Product Name Group Product Group Numbers
Blue Advantage
(PMAP)
PP011, PP012, PP014, PP015, PP016,
PP017, PP021, PP022, PP024, PP025,
PP026, PP027, PP031, PP032, PP034,
PP035, PP036, PP037
MinnesotaCare PP111, PP112, PP151, PP152, PP121,
PP122, PP131, PP132, PP141, PP142,
PP161, PP162, PP163, PP164
Minnesota Senior Care
Plus (MSC+)
SecureBlue
PP041, PP042, PP044, PP051, PP052,
PP054, PP055, PP056, PP057, PP061,
PP062, PP064, PP071, PP072, PP074,
PP075, PP076, PP077
All group numbers that begin with PP2
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (02/07/12)
11-21

Coding Policies and Guidelines (Public Programs)
Chiropractic, Physical,
Occupational, and
Speech Therapy
Authorization
(continued)
11-22
Outpatient physical, occupational and speech therapy services:
Initial evaluation
Any additional evaluations
Plan of Care including the following:
Member’s diagnosis
Description of member’s functional status / limitations
Treatment plan
Treatment goals (functional, measurable and time-specific)
Requested frequency and expected duration of treatment
Discharge plan
Member’s progress toward goals
Ordering practitioner
Documentation Required
Prior authorization requests should be submitted two weeks in
advance of reaching the visit threshold as listed above. Fax your
Blue Plus member requests to: (651) 662-4022 or
1-866-800-1665.
Submit the following documentation when requesting an
authorization:
Chiropractic services:
Evaluation and diagnosis: Indicate how the subluxation
diagnosis was determined
Chief complaint: List member’s current symptoms
Assessment and treatment plan: Provide your physical
assessment and treatment plan including when the member will
be discharged, number of visits planned and frequency of visits
planned
Rationale for continued treatment: Provide evidence of
member’s improvement with chiropractic services and goals
for further care
The completed Chiropractic Medical Information Request
form, available in the forms section of
providers.bluecrossmn.com.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (02/07/12)

Chiropractic, Physical,
Occupational, and
Speech Therapy
Authorization
(continued)
Coding Policies and Guidelines (Public Programs)
Outpatient physical, occupational and speech therapy services:
Initial evaluation
Any additional evaluations
Plan of Care including the following:
Member’s diagnosis
Description of member’s functional status / limitations
Treatment plan
Treatment goals (functional, measurable and time-specific)
Requested frequency and expected duration of treatment
Discharge plan
Member’s progress toward goals
Ordering practitioner
Prior Authorization Process
The timeline for decisions is up to ten business days. Decisions
will be communicated via telephone or fax, and letter. Approvals
are communicated via telephone with a letter as follow-up. Denials
are communicated with a fax copy of the denial letter and a followup
letter sent by mail.
MHCP coverage guidelines are followed for MHCP members. All
services must be medically necessary for continued coverage.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (02/07/12)
11-23

Coding Policies and Guidelines (Public Programs)
Services to Restricted
Recipients
11-24
Under the Minnesota Restricted Recipient Program, either the
Department of Human Services (DHS) or Blue Plus identifies
members of Blue Plus MHCP who have used Medicaid services,
most often prescription drugs or emergency rooms visits for nonemergent
reasons, at a frequency or amount that is not medically
necessary and/or who have used health care services that resulted
in unnecessary costs to the program. Once identified, such
recipients will be placed under the care of a primary care physician
and/or other designated providers who will coordinate their care
for a 24-month or a 36-month period. Although other members of
Blue Plus Minnesota Health Care programs require a referral only
to nonparticipating providers, all services to a restricted recipient
from other than the designated primary care physician require a
referral.
Restricted Recipient Program
Placement in the Restricted Recipient Program means that for a
period of twenty-four (24) or thirty six (36) months of eligibility,
the enrollee must obtain health care services from:
A designated primary care provider located in the enrollee’s or
recipient’s local trade area
A hospital used by the primary care provider
A designated pharmacy
The restriction may include any other type of health care service
from a designated provider, including services from a Blue Plus
participating Personal Care Provider Organization (PCPO).
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (02/07/12)

Services to Restricted
Recipients (continued)
Coding Policies and Guidelines (Public Programs)
The DHS and health plans have developed a universal restriction,
which is put in place by either the DHS or a health plan, and stays
in effect for the entire period of restriction, regardless of whether
the recipient does any of the following:
Changes health plans
Moves from fee-for-service to a health plan
Moves from a health plan to fee-for-service
If you are a designated primary care provider, you can verify this
and the restricted recipient status of a member through Blue Plus
provider service or through MN-ITS, the Minnesota Department of
Human Services (DHS) billing system, at
www.mn-its.dhs.state.mn.us/login.html. Typically, a recipient is
restricted to one primary care physician, pharmacy and hospital. A
recipient may also be restricted to other designated providers or be
referred by the primary care physician to other providers, if
appropriate. When a member is restricted only for certain types of
services, no referral is required to restriction.
Claims Reimbursement
Eligible services provided to a restricted recipient will only be
reimbursed when one of the following criteria is met:
The service is provided by the recipient's primary care
physician or his/her designee
The primary care physician has made a referral to another
provider
The service is of a provider type or type of service that is not
listed as restricted on the recipient's file
Additional Information
Providers may access more information about the Minnesota
Restricted Recipient Program on the DHS website with the
following link:
www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMI
C_CONVERSION&RevisionSelectionMethod=LatestReleased
&dDocName=id_008922#mrrp.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (02/07/12)
11-25

Coding Policies and Guidelines (Public Programs)
MHCP Changes in Prior
Authorization
11-26
Unless otherwise noted, prior authorization is required for the
services listed below for Minnesota Health Care products.
Commercial lines of business are not impacted by this change.
Minnesota Health Care Programs
Group numbers for the affected Blue Plus products are as follows:
Product Name Group Numbers
Blue Advantage (PMAP &
GAMC)
PP011, PP012, PP014, PP015,
PP016, PP017, PP021, PP022,
PP024, PP025, PP026, PP027,
PP031, PP032, PP034, PP035,
PP036, PP037, PP081, PP082,
PP084, PP091, PP092, PP094
MinnesotaCare PP111, PP112, PP121, PP122,
PP131, PP132, PP141, PP142,
PP151, PP152, PP161, PP162,
PP163, PP164
Minnesota Senior Care Plus
(MSC+)
PP041, PP042, PP044, PP051,
PP052, PP054, PP055, PP056,
PP057, PP061, PP062, PP064,
PP071, PP072, PP074, PP075,
PP076, PP077
SecureBlue All group numbers that begin
with PP2
CareBlue All group numbers that begin
with PP3
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (02/07/12)

Prior authorization changes
Coding Policies and Guidelines (Public Programs)
For Blue Advantage, MinnesotaCare, MSC+, SecureBlue and CareBlue members, prior
authorization is required for the services listed below.
15780 15781 15782 15783 15786
15787 15819 15820 15821 15822
15823 17340 17360 19304 19328
20975 21010 21110 21255 21485
29870 29873 29874 29875 29876
29877 29878 29879 29880 29881
29882 29883 29884 29885 29886
29887 33140 33141 33975 33976
33979 35400 37788 37790 43280
43325 43850 43855 43860
43865 48160 51715 54400 55401
54405 54660 64622 64623 64626
64627 64640 67345 67901 67902
67903 67904 67906 67909 67911
69930 76390 77058 77605
77610 77615 77620 78459 78491
78492 78607 78608 78609 78811
78812 78813 78814 78815 78816
91110 91111 93784 93786 93788
93790
0159T
C8903 C8904 C8905 C8906 C8907
C8908 G0166 G0252 G0289 S2400
S2401 S2402 S2403 S2404 S2405
S2409 S3823 S8035
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (02/07/12)
11-27

Coding Policies and Guidelines (Public Programs)
MHCP Changes in Prior
Authorization
(continued)
11-28
Additional Information
MHCP coverage guidelines are followed for Minnesota Health
Care members. All services must be medically necessary for
coverage.
To obtain prior authorization, providers should complete the Pre-
Service Request Form located on the Blue Cross website at
providers.bluecrossmn.com.
To assure timeliness of the review, please submit your request
form at least 14 days in advance of the procedure whenever
possible.
Medical Necessity Criteria
To view the medical necessity review criteria for these services go
to providers.bluecrossmn.com and select “Medical Policy” under
“Tools & Resources.” The website includes links to:
Prior Authorization Recommendations (Government
Programs)
Coverage Guidelines for DHS Programs
Coding Requirements Reminder
All coding and reimbursement is subject to changes, updates, or
other requirements of coding rules and guidelines. All codes are
subject to federal HIPAA rules, and in the case of medical code
sets (e.g., HCPCS, CPT, ICD-9-CM), only valid codes for the date
of service may be submitted or accepted.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (02/07/12)

Special Transportation Special Transportation
Coding Policies and Guidelines (Public Programs)
Effective January 1, 2012, all Special Transportation rides must be
scheduled through the BlueRide staff. The Special Transportation
Services (STS) providers may not schedule or provide rides
requested directly by members or their representatives. Any such
requests are not eligible for coverage.
BlueRide will schedule the rides and fax information to the STS
providers directly with the detailed information regarding the
rides. It will be imperative that STS providers keep all
administrative information up to date at Blue Plus.
BlueRide can be reached at (651) 662-8648 or toll-free at
1-866-340-8648. Although BlueRide will occasionally schedule
same-day rides depending on provider availability, we require at
least 24 hours in advance in the metro area and two business days
in advance for greater Minnesota.
STS providers will be notified of scheduled rides via fax from the
BlueRide staff.
Physician Certification of Need (CON)
All non-institutionalized eligible MHCP Members must have a
complete, signed CON on file with the STS provider and Blue Plus
prior to the provision of STS transportation. Signed forms will be
valid for one year from date of the medical provider’s signature.
Any CONs that are incomplete or unreadable will be considered
invalid, rejected, and returned to the STS provider. CONs must be
faxed by the STS provider to BlueRide at (651) 662-2844 before
transportation is provided.
Claims submitted for services provided without a valid CON on
file at Blue Plus will not be paid.
Medical providers are NOT obligated to sign a CON. The medical
provider will use their professional judgment to determine if the
member requires special transportation and indicate that on the
CON.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (02/07/12)
11-29

Coding Policies and Guidelines (Public Programs)
Special Transportation
(continued)
11-30
Special Transportation Trip Sheet
STS providers must maintain a special transportation services trip
sheet documenting each ride that is provided to eligible MHCP
Members. The completed trip sheets must be filed in the STS
provider’s office and available for inspection and review by Blue
Plus.
Reimbursement
Reimbursement for services will only be allowed, and should only
be billed, when the transportation is to or from a covered medical
or dental service for an eligible MHCP member. Some examples
of covered medical services are clinic visits, therapies, eye exams,
etc. Appropriate modifiers must be used when billing for services.
An eligible MHCP member is defined as a member who is
physically or mentally impaired in a manner that keeps him/her
from safely accessing and using common carrier transportation. If
an eligible MHCP member does not meet this definition and is in
need of transportation, please refer them to BlueRide at
1-866-340-8648 so they may talk to a representative.
Point of Pick up Zip Code
STS providers must submit the point-of-pickup zip code on all
claims. This information should be submitted on an 837P
transaction in the 2310D loop. If this information is not submitted,
the services will be denied.
Minnesota rule
Per Minnesota Rule 9505.0315 “One-way mileage for special
transportation within the recipient’s local trade area must not
exceed 20 miles for a trip originating in the seven-county
metropolitan area or 40 miles for a trip originating outside of the
seven-county metropolitan area if a similar health service is
available within the mileage limitation.” Blue Plus requires full
compliance with all applicable state and federal laws as stated in
the Provider Service Agreement between Blue Plus and the
provider.
These provisions, along with all Provider Service Agreement
requirements are subject to audit at any time by Blue Plus.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (02/07/12)

Chapter 11
Coding Policies and Guidelines
(Radiology Services)
Table of Contents
General Guidelines............................................................................................................... 11-2
Diagnosis..............................................................................................................................11-2
Modifiers..............................................................................................................................11-2
Radiation Treatment Management.......................................................................................11-2
Maternity Ultrasound Compatibility....................................................................................11-3
Purchased Services/ Outside Lab......................................................................................... 11-3
Diagnostic and Screening Mammogram..............................................................................11-4
76140.................................................................................................................................... 11-4
Comparison X-ray................................................................................................................ 11-4
High-Technology Diagnostic Imaging (HTDI) program..................................................... 11-5
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (03/06/2012) 11-1

Coding Policies and Guidelines (Radiology Services)
General Guidelines Codes 70010-79999 are used for reporting radiology procedures.
The number of services on your claim must be the number of
procedures performed, not the number of views taken.
For example:
Code Number of Services
71020 (chest X-ray, two views) 1
Diagnosis A diagnosis code is required for radiology services and should
match the services provided. For example, 76805 should have a
maternity diagnosis.
For a preoperative chest X-ray, use ICD-9 code V72.82.
Modifiers Use modifier -26 to indicate a physician’s professional component
when only the professional component is reported. Likewise, if
only the technical component is being reported, modifier -TC
should be added to the CPT code. We expect the global procedure
to be reported if both components are performed by personnel in
the same clinic.
Radiation Treatment
Management
11-2
Examples:
•
•
•
Global – 71010
Professional only – 71010-26
Technical only – 71010-TC
Professional bilateral radiology services are reported as two lines
with LT and RT modifiers.
The weekly management code is 77427. Radiation treatment
management is reported in units of five fractions or treatment
sessions, regardless of the actual time period in which the services
are furnished. The services need not be furnished on consecutive
days. Multiple fractions representing two or more treatment
sessions furnished on the same day may be counted separately as
long as there has been a distinct break in therapy sessions, and the
fractions are of the character usually furnished on different days.
Code 77427 is also reported if there are three of four fractions
beyond a multiple of five at the end of a course of treatment; one
or two fractions beyond a multiple of five at the end of a course of
treatment are not reported separately.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (03/06/2012)

Radiation Treatment
Management Codes
(continued)
Maternity Ultrasound
Compatibility
Purchased Services/
Outside Lab
Coding Policies and Guidelines (Radiology Services)
The professional services furnished during treatment management
typically consists of:
•
•
•
•
Review of port films;
Review of dosimetry, dose delivery, and treatment parameters;
Review of patient treatment set-up;
Examination of patient for medical evaluation and
management (e.g., assessment of the patient’s response to
treatment, coordination of care and treatment, review of
imaging and/or lab test results.)
The code 77431 is meant to be utilized for radiation therapy
management that includes the complete course of therapy,
consisting of one or two fractions only. This code is not meant to
fill in the gaps for the one or two fractions that may be left over at
the end of a long course of therapy.
The pregnant uterus ultrasound CPT codes 76801-76817 are not
compatible with routine or non-specific diagnoses. This includes
the diagnosis code V72.5 (Radiological examination, not
elsewhere classified). If a definitive diagnosis is not available, a
sign or symptom necessitating the ultrasound should be submitted.
The entity that performs a test should be the one to bill for that
test. However, a provider may, under arrangement with another
provider, bill a service that is purchased from that other provider.
For example, a clinical provider may bill for an X-ray that is done
at a hospital because the clinic did not have the appropriate
equipment. It is important to remember that only one provider may
bill for the service.
Claims for purchased services should be submitted on the
electronic 837 professional format as follows:
•
•
•
•
•
Place of service – enter the place of service code where the
service was done by the performing provider.
Procedure/modifier – enter the procedure code of the test and
the modifier 90.
Provider ID – enter the NPI provider number of the ordering
physician.
Service facility location – enter the name and address of the
service facility along with the applicable NPI.
Billing Provider – enter the NPI provider number of the billing
provider.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (03/06/2012)
11-3

Coding Policies and Guidelines (Radiology Services)
Diagnostic and
Screening
Mammogram
Generally, screening and diagnostic services done on the same day
are considered mutually exclusive and the screening service will
be denied. However, if a diagnostic mammogram is followed by a
screening mammogram on the same day, both may be allowed.
The modifier –GG must be appended to the diagnostic
mammogram code.
76140 Code 76140 (consultation on X-ray examination made elsewhere,
written report) is considered an overread, thus it is not allowed.
Overreads are an additional interpretation of a film and as such, are
not billable to the plan or the patient as a separate charge.
Comparison X-ray X-rays taken for comparison purposes are generally not covered.
Re-X-rays are allowed if performed at different times of day or
before and after surgery, such as orthopedic procedures including
casting. Appending a repeat modifier (-76 or -77) will not be
allowed; however, the repeat charge may be considered on appeal.
11-4
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (03/06/2012)

High-Technology
Diagnostic Imaging
(HTDI) program
Coding Policies and Guidelines (Radiology Services)
Blue Cross has a relationship with Nuance for the Institute of
Clinical Systems Improvement (ICSI) sponsored HTDI automated
decision support program.
Key process changes
Ordering providers are required to use a decision support system as
part of their process for ordering elective, outpatient HTDI
procedures. This can be performed either by Electronic Medical
Record (EMR) integrated RadPort software or the web-based
version. Those providers using other previously approved decision
support systems may continue doing so.
This program applies to the following Blue Cross products:
• Blue Cross fully insured members
• A limited number of Blue Cross self-insured Minnesota
members
• Blue Plus members enrolled in Minnesota Health Care
Programs (MHCP)
All providers must continue to follow Medical and Behavioral
Health Policies for selected HTDI procedures as summarized in
the section below.
For more information about the RadPort tool, and to schedule
implementation, contact ICSI at (952) 814-7067 or
htdi@icsi.org.
Imaging procedures included in the automated decision
support HTDI program
The new program covers the following elective, outpatient
HTDI procedures:
• Computed tomography and angiography (CT/CTA) scans
• Positron emission tomography (PET scans)
• Magnetic resonance imaging and magnetic resonance
angiography (MRI/MRA) scans
• Nuclear cardiology scans
• Combinations of PET, CT, MRI, etc.
Medical and behavioral health policies relating to HTDI
(existing requirements)
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (03/06/2012)
11-5

Coding Policies and Guidelines (Radiology Services)
High-Technology
Diagnostic Imaging
(HTDI) program
(continued)
11-6
All providers must follow current pre-certification/pre-authorization
and investigative policies in the Medical and Behavioral Health
Policy Manual for commercial products. The following procedures
have coverage criteria, are subject to medical review and continue to
require the standard pre-certification/pre-authorization process:
•
•
•
• MRI of the breast
• CT colonography (virtual colonoscopy) as a screening test for
colorectal cancer
• Computed tomography angiography (CTA) for evaluation of
coronary arteries, including coronary CT and EBCT for calcium
scoring
• PET scans
• SPECT scans case-by-case review
• Capsule endoscopy
Non-covered procedures
•
•
•
Computed tomography angiography (CTA) for evaluation of
coronary arteries
(retrospective claim review to determine if medical necessity
criteria met)
CT colonography (virtual colonoscopy) as a screening test for
colorectal cancer (pre-certification/pre-authorization required)
MRI of the breast
(pre-certification/pre-authorization required EXCEPT in
individuals with biopsy-proven breast cancer)
• Positron emission tomography (PET)
(retrospective claim review to determine if medical necessity
criteria met)
MHCP:
All providers must follow current prior authorization and
investigative policies in the Medical and Behavioral Health Policy
Manual for MHCP as defined in your Provider Service Agreement.
The following procedures continue to require the standard precertification/pre-authorization
process:
These procedures are not covered for either commercial or MHCP
members:
Computed tomography (CT) screening for coronary artery disease
Full-body CT scanning
Spiral CT screening for lung cancer
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (03/06/2012)

High-Technology
Diagnostic Imaging
(HTDI) program
(continued)
Members covered by the program
Coding Policies and Guidelines (Radiology Services)
This program includes the following Blue Cross lines of business:
• Blue Cross fully insured members
• A limited number of Blue Cross self-insured Minnesota members
• Blue Plus members enrolled in Minnesota Health Care Programs
(MHCP)
The HTDI program does not apply to any Medicare products or the
Federal Employee Program.
The EMR integrated RadPort software or the web-based version will
display the member's name if they are included under the HTDI
program. (Blue Cross membership feeds to RadPort contain only
members who are part of HTDI program, so if the member is not
displayed in RadPort that member is not included.)
Contact information
For more information about pre-certification/pre-authorization and
medical necessity requirements, etc., please contact provider services at
(651) 662-5200 or 1-800-262-0820.
For more information about the HTDI program, go to
providers.bluecrossmn.com.
For specific questions about Nuance’s RadPort tool, or to schedule
training and implementation of the tool, contact ICSI at
(952) 814-7067 or htdi@icsi.org.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (03/06/2012)
11-7

Chapter 11
Coding Policies and Guidelines
(Rehabilitative Services)
Table of Contents
Physical Therapy Modalities................................................................................................11-2
Physical Therapy Procedures...............................................................................................11-2
Physical Therapy Evaluation Codes .................................................................................... 11-3
Occupational Therapy.......................................................................................................... 11-3
Occupational Therapy Evaluation Codes............................................................................. 11-4
Hot and Cold Pack Exclusion .............................................................................................. 11-5
TMJ Orthotic Adjustments .................................................................................................. 11-5
Massage and Manual Therapy Exclusion ............................................................................ 11-5
Speech Therapy and Evaluation........................................................................................... 11-7
“Timed” Unit Reporting ...................................................................................................... 11-7
MHCP PT, OT, ST Authorization Process ..........................................................................11-8
Medical Necessity Vendor.................................................................................................11-10
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (03/19/12) 11-1

Coding Policies and Guidelines (Rehabilitative Services)
Physical Therapy
Modalities
Physical Therapy
Procedures
11-2
The following physical medicine codes require a physician or
therapist to be in constant attendance. Submit the following CPT
codes for physical therapy services:
Code Units of Service
97010-97028, 97039 1 unit for each modality
97032-97036 1 unit for each 15 minutes
The following codes should be used for physical therapy
procedures:
Code Units of Service
97110- 97124 1 unit for each 15 minutes.
Example:
Coding for therapeutic exercises, 50 minutes:
Code Time Units of Service
97110 50 min. 3
For procedures that include time increments, over 50 percent of the
indicated time must be rendered and documented in order to bill an
additional unit. In the above example, only three units may be
submitted – three units for the first 45 minutes. The remaining five
minutes may not be reported because it is less than 50 percent of
the 15-minute code increment.
Additional physical therapy codes 97140-97542 and 97597-97606
should be used as defined in CPT.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (03/19/12)

Physical Therapy
Evaluation Codes
Coding Policies and Guidelines (Rehabilitative Services)
Physical therapists evaluation and re-evaluation services should be
submitted using CPT codes 97001 and 97002.
Code Category Units of Service
97001-97002 Evaluation and re-evaluation 1 unit
These codes may be reported separately if the patient’s condition
requires significant separately identifiable services, above and
beyond the usual pre-service and post-service work associated with
the procedure performed.
The modifier -25 (significant, separately identifiable evaluation
and management service by the same physician on the same day as
the procedure or other service) is not valid with the physical
therapy (PT) evaluations and re-evaluation codes 97001-97002.
The evaluation or re-evaluation codes will be allowed, as
appropriate, when billed with other physical or occupational
services on the same date. Because the modifier -25 is not valid
with 97001-97002, if submitted, the service will be denied.
Occupational Therapy Listed below are the CPT physical medicine and rehabilitation
codes and additional codes that occupational therapists may
submit.
Code Category Units of Service
97010-97028 Modalities, supervised 1 unit for each modality
97032-97036 Modalities, constant
attendance
97039 Modality, constant
attendance, unlisted
1 unit for each 15
minutes
1 unit
97110-97140 Therapeutic procedures 1 unit for each 15
minutes
97150 Therapeutic
procedure(s), group
1 unit
97530-97542 Therapeutic procedures 1 unit for each 15
minutes
97545 Therapeutic procedures 1 unit
97546 Therapeutic procedures 1 unit for each additional
60 minutes
97597-97606 Active wound
management
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (03/19/12)
Unit per session
11-3

Coding Policies and Guidelines (Rehabilitative Services)
Occupational Therapy
(continued)
Occupational Therapy
Evaluation Codes
11-4
Code Category Units of Service
97750-97755 Test and measurements 1 unit for each 15
minutes
97760-97762 Orthotic and Prosthetic
management
1 unit for each 15
minutes
97799 Other procedures 1 unit (designate time)
29105-29131
and 29505-
29515
Splints 1 unit
29240-29280 Strapping 1 unit
92526,
92610-92617
95831-95852
and 95999
Special
otorhinolaryngologic
services
Neurology and
neuromuscular
procedures
1 unit
1 unit
96105 Aphasia assessments 1 unit per hour
96110-96111 Developmental testing 1 unit
Occupational therapists should submit evaluation and re-evaluation
services using the CPT codes 97003 and 97004.
Code Category Units of Service
97003-97004 Evaluation and reevaluation
1 unit
These codes may be reported separately if the patient’s condition
requires significant separately identifiable services, above and
beyond the usual pre-service and post-service work associated with
the procedure performed.
The modifier -25 (significant, separately identifiable evaluation
and management service by the same physician on the same day as
the procedure or other service) is not valid with the occupational
therapy (OT) evaluations and re-evaluation codes 97003-97004.
The evaluation or re-evaluation codes will be allowed, as
appropriate, when billed with other physical or occupational
services on the same date. Because the modifier -25 is not valid
with 97003-97004, if submitted, the service will be denied.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (03/19/12)

Hot and Cold Pack
Exclusion
TMJ Orthotic
Adjustments
Massage and Manual
Therapy Exclusion
Coding Policies and Guidelines (Rehabilitative Services)
Blue Cross and Blue Shield of Minnesota (Blue Cross) will not
reimburse providers for the physical medicine hot and cold pack
modality, CPT code 97010.
Blue Cross reviewed the utilization of the hot and cold pack
therapy code and determined that this modality is used in
conjunction with and/or to enhance other services performed.
Thus, 97010 will be denied as provider liability, whether billed
alone or with another service.
Adjustments for TMJ orthotics are normally billed under CPT
codes 97760 or 97762. These services are not separately covered
with a TMJ diagnosis. These adjustments are considered an
integral part of the splint therapy and as such will be denied
regardless if billed alone or with another service.
97760 Orthotic(s) management and training (including
assessment and fitting when not otherwise reported), upper
extremity(s), lower extremity(s) and/or trunk, each 15 minutes
97762 Checkout for orthotic/prosthetic use, established patient,
each 15 minutes
Blue Cross will not reimburse providers for massage or manual
therapy services. Massage or manual therapy will deny either as
incidental (provider liability) or subscriber liability.
Massages that are provided as preparation for a physical medicine
therapy are considered an integral part of the therapy. As such, we
will deny it as provider liability. If a massage is billed alone, then
it may be denied as a subscriber contract exclusion.
Codes
97124 Therapeutic procedure, one or more areas, each 15
minutes; massage, including effleurage, petrissage and/or
tapotement (stroking, compression, percussion).
97140 Manual therapy techniques (e.g. mobilization /
manipulation, manual lymphatic drainage, manual traction),
one or more regions, each 15 minutes.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (03/19/12)
11-5

Coding Policies and Guidelines (Rehabilitative Services)
Massage and Manual
Therapy Exclusion
(continued)
11-6
Liability
Provider liable:
Massage and manual therapy (97124 and 97140) may be denied
incidental or mutually exclusive (provider liable) to physical
medicine procedures billed on the same date of service. The code
combinations and outcomes are listed below. For information on
incidental and mutually exclusive edits refer to Chapter 11, Coding
section. The denial will be upheld regardless of submission of the -
59 modifier. Additionally, submission of the -GA modifier will not
affect or change the denial. Note that the Blue Cross and Blue
Shield of Minnesota Provider Policy and Procedure Manual,
Chapter 11, Coding section prohibits billing a patient where
payment is denied as the result of a coding edit:
Massage therapy – 97124 will be denied incidental to the
following codes:
97110, 97112-97113, 97116, 97139-97140, 97150, 97530,
97532-97533, 97535, 97537, 97542, 97545-97546, 98925-
98929, 98940-98943
Manual therapy – 97140 will be denied incidental to the
following codes:
97139, 97150, 97545-97546
Manual therapy – 97140 will be denied mutually exclusive to the
following codes:
97530, 97532-97533
Manual therapy – 97140 currently denies incidental to the
following codes:
98925-98943
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (03/19/12)

Massage and Manual
Therapy Exclusion
(continued)
Speech Therapy and
Evaluation
Patient Billing Impact
Coding Policies and Guidelines (Rehabilitative Services)
The patient is not responsible and must not be balance billed for
any procedures for which payment has been denied or reduced by
Blue Cross as the result of a coding edit. Edit denials are designed
to ensure appropriate coding and to assist in processing claims
accurately and consistently.
Subscriber liable:
Coverage for massage and manual therapy (97124 and 97140)
services provided without a physical medicine therapy is subject to
the subscriber’s contract benefits. Some benefit plans may not
cover this service.
Speech therapists, physicians, or M.D. clinics should use CPT
code 92507 for their speech therapy services and 92506 for speech
evaluation. Submit one unit of service per encounter.
If a speech evaluation is done over a period of two days, but only
one report is generated, submit 92506 only once on the day the
evaluation is completed.
“Timed” Unit Reporting When a procedure/service indicates time, more than half of the
designated time must be spent performing the service in order for a
unit to be billed. In the case of a 15 minute service - at least 8
minutes must be performed, for a 30 minute service - at least 16
minutes, for a 60 minute service - at least 31 minutes, and so on.
If more than one modality or therapy is performed, time cannot be
combined to report units. Do not follow Medicare’s rounding rules
for speech, occupational, and physical therapy services. Each
modality and unit(s) is reported separately by code definition. Do
not combine codes to determine total time units.
For example, if two 15 minute defined modalities are performed
but only 7 minutes or less is spent per modality, neither service
should be reported.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (03/19/12)
11-7

Coding Policies and Guidelines (Rehabilitative Services)
MHCP PT, OT, ST
Authorization Process
11-8
The following services provided to Minnesota Health Care
Program (MHCP) subscribers will require pre-authorization by
Blue Cross:
Physical therapy visits beyond 40 visits per calendar year
Occupational therapy visits beyond 40 per calendar year
Speech therapy visits beyond 50 per calendar year
Commercial lines of business are not impacted by this change.
Minnesota Health Care Programs affected:
Product Name Group Numbers
Blue Advantage (PMAP) PP011, PP012, PP014, PP015,
PP016, PP017, PP021, PP022,
PP024, PP025, PP026, PP027,
PP031, PP032, PP034, PP035,
PP036, PP037, PP4411, PP412,
PP414
MinnesotaCare PP111, PP112, PP151, PP152,
PP121, PP122, PP131, PP132,
PP141, PP142, PP161, PP162,
PP163, PP164
Minnesota Senior Care Plus
(MSC+)
PP041, PP042, PP044, PP051,
PP052, PP054, PP055, PP056,
PP057, PP061, PP062, PP064,
PP071, PP072, PP074, PP075,
PP076, PP077
SecureBlue SM (HMO SNP) All group numbers that begin
with PP2
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (03/19/12)

MHCP PT, OT, ST
Authorization Process
(continued)
Documentation required
Coding Policies and Guidelines (Rehabilitative Services)
Pre-Authorization requests should be submitted 2 weeks in
advance of reaching the visit threshold as listed above. Fax your
Blue Cross subscriber requests to: (651) 662-4022 or
1-866-800-1665.
Submit the following documentation when requesting an
authorization:
Outpatient physical, occupational and speech therapy services:
Initial evaluation
Any additional evaluations
Plan of Care including the following:
Subscriber’s diagnosis
Description of subscriber’s functional status / limitations
Treatment plan
Treatment goals (functional, measurable and time-specific)
Requested frequency and expected duration of treatment
Discharge plan
Subscriber’s progress toward goals
Ordering practitioner
Pre-Authorization process
The timeline for decisions is up to 10 business days. Decisions will
be communicated via telephone or fax, and letter. Approvals are
communicated via telephone with a letter as follow-up. Denials are
communicated with a fax copy of the denial letter and a follow-up
letter sent by mail.
MHCP coverage guidelines are followed for Minnesota Health
Care Programs subscribers. All services must be medically
necessary for continued coverage.
Effective February 1, 2012, Specialized Maintenance Therapy is
covered only for children under 21 years of age.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (03/19/12)
11-9

Coding Policies and Guidelines (Rehabilitative Services)
Medical Necessity
Vendor
11-10
Blue Cross, Commercial Blue Plus, and BlueLink TPA have an
agreement with McKesson Health Solutions, who provides
medical necessity criteria for the majority of hospitals and health
care systems in Minnesota, for use of their InterQual Medical
Necessity Criteria.
Effective March 26, 2012, clinicians, peer reviewers, and appeals
reviewers will utilize this tool to determine medical necessity and
level of care review for inpatient, long-term acute care, and acute
rehabilitation admissions and length of stay. Criteria are available
for review, on a case-by-case basis, upon request. The Blue Cross
clinician who is communicating the results of the case review will
be able to assist you with your questions.
We will extend the use of the McKesson Interqual criteria to
behavioral health and chemical dependency, along with
chiropractic, physical therapy, occupational therapy, speech
therapy, home health care, and skilled nursing facility reviews on
April 1, 2012.
Government Programs will also be using McKesson InterQual
Criteria, in addition to Medicare and MHCP guidelines, for
inpatient care, long-term acute care, acute rehabilitation care and
behavioral health services.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (03/19/12)

Chapter 11
Coding Policies and Guidelines
(Surgical Services)
Table of Contents
General Guidelines............................................................................................................... 11-2
Bilateral Services .................................................................................................................11-2
Unlisted Procedures ............................................................................................................. 11-3
Facility Fees for Office Surgery .......................................................................................... 11-3
Global Surgical Package......................................................................................................11-4
Fractures............................................................................................................................... 11-5
Incidental Surgery................................................................................................................ 11-5
Lesions ................................................................................................................................. 11-5
Surgical Trays and Supplies.................................................................................................11-5
Implanted Supplies / Devices...............................................................................................11-6
Standby Services.................................................................................................................. 11-6
Treatment of Warts .............................................................................................................. 11-6
Acne Treatment/Skin Rejuvenation and Rosacea Treatment .............................................. 11-6
Anesthetic Agent Injections.................................................................................................11-7
Intra-articular Hyaluronan Injections for Osteoarthritis ...................................................... 11-8
Liposuction Edit Change...................................................................................................... 11-9
Assistant Surgeons.............................................................................................................11-10
Co-Surgeons.......................................................................................................................11-11
Multiple Surgeries.............................................................................................................. 11-12
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (03/19/12) 11-1

Coding Policies and Guidelines (Surgical Services)
General Guidelines Generally, Blue Cross covers only surgical procedures performed
by a physician for the treatment of illness or injury.
Follow these procedures to bill surgical charges:
Submit each surgical procedure on a separate line.
Surgical units:
Most surgical procedures should be submitted only with one
unit; however, we can accept more than one unit for those
surgical procedure codes whose narrative includes a unit
indicator, such as “each” or “per.” For example, 11201 is an
add-on code to 11200. Code 11201 indicates “each additional
10 lesions.” If 35 skin tags are removed, code 11200 would be
reported with one unit for the first 15 lesions. Code 11201
could be reported with two units for the additional 20 skin tags.
Submit all surgeries performed on the same date on one claim.
List the appropriate procedure code for each one.
Modifier -51 may be used for secondary procedures but is not
required.
Bilateral Services The bilateral modifier –50 is used to indicate cases in which a
procedure normally performed on only one side of the body is
performed on both sides. The CPT descriptors for some procedures
specify that the procedure is bilateral. In such cases, the bilateral
modifier should not be used. Blue Cross requires submission of
one line for bilateral procedures. Correctly submitted services will
be eligible for 150 percent of the procedure allowed amount.
11-2
Certain edits apply to bilateral services:
If a CPT defined bilateral procedure is submitted with a -50
modifier, the service will be denied based on submission of an
incorrect procedure/modifier combination.
If more than one line of the same procedure code is submitted
– one with the -50 modifier and one without – the unmodified
line(s) will be denied as duplicative.
Bilateral services on claims resubmitted will need to be
submitted using the one-line reporting method regardless of the
date of service.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (03/19/12)

Bilateral Services
(continued)
Coding Policies and Guidelines (Surgical Services)
Bilateral billing for freestanding Ambulatory Surgical Centers
Because Medicare differs in bilateral billing instructions for
freestanding ASCs, the Minnesota Rule found in Table A.5.1 of
the Minnesota Department of Health Minnesota Companion Guide
clarifies the bilateral modifier rules for Minnesota providers and
payers.
Modifier 50 should be used on surgical services that can be
performed bilaterally and are not already defined as a bilateral
service. When appropriate, report the service appended with the 50
modifier on one line with one unit.
Professional bilateral radiology services are reported as two lines
with LT and RT modifiers.
Unlisted Procedures If a code cannot be found for a surgical procedure, submit the
unlisted code from the related section of CPT and attach an
operative report to the claim. If not attached, records will not be
requested and the claim will not be processed without the
information.
Facility Fees for Office
Surgery
Blue Cross does not allow a separate reimbursement for approved
office surgery suites. No additional reimbursement will be made
for fees associated with procedures performed in office surgical
suites regardless if the service(s) is modified with the –SU or –SG
modifier. This includes additional units of service for the
preoperative preparation, anesthesia and surgical trays.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (03/19/12)
11-3

Coding Policies and Guidelines (Surgical Services)
Global Surgical
Package
11-4
Surgical procedures include the operation itself, local infiltration,
metacarpal/digital block or topical anesthesia, when used, and
normal, uncomplicated follow-up care. This concept is referred
to as a ‘‘package’’ for surgical procedures, and typically begins the
day before surgery. Do not submit separate, itemized services for
uncomplicated surgical follow-up.
Surgeries should be billed globally (one line, one charge,
unmodified) if the surgery itself, pre- and post- op services are
performed by either by the same practitioner or by different
practitioners from the same practice/under the same tax ID. If
different practitioners under different tax IDs perform different
portions of the surgical package, the pre-, intra-, and post-op
services should be split and billed appropriately.
Surgical Care Only
The post-operative period includes all visits by the primary
surgeon unless the visit is for a problem unrelated to the diagnosis
for which the surgery was performed or is for an added course of
treatment other than the follow-up care that is usually associated
with the surgical procedure.
When billing for the surgery only, submit the surgical procedure
code with a -54 modifier and an appropriately reduced charge to
reflect that post-operative care was not provided. Reimbursement
for allowable intraoperative services will reflect 90 percent of the
physician fee schedule allowance for the procedure.
Pre- or Post-op Management
When billing for pre- and/or post-operative services only, submit
the surgical procedure code with the modifier -55 or -56 as
appropriate. Pre- and/or post-operative services are billed only one
time and include all visits within the designated period. Thus only
one payment will be made for the pre- and/or post-op care.
If care during the post-operative period is relinquished to another
practitioner from a different practice, both practitioners should bill
for their portion of post-operative care also with the surgical
procedure code and the -55 modifier. However, both practitioners
must report the date the care was relinquished. Assumed and
relinquished care is reported in the 2300 loop/DTP03 of the
electronic claim record.
The reimbursement for the post-op care will be divided between
the practitioners based on each practitioner’s portion of their postop
care.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (03/19/12)

Coding Policies and Guidelines (Surgical Services)
Fractures Codes for fracture treatment include the application and removal
of the first cast. Do not submit separate charges for these casting
services. Submit cast removal codes only if a different physician
does the removal.
Submit codes 29000-29590 for the application of casts and
strapping only when performed as a replacement during the period
of follow-up care, per CPT. Additional visits are reportable only if
additional significantly identifiable services are provided at the
time of the cast application or strapping. Removal of a second or
third cast by the physician who applied it is included in the casting
and strapping codes and not billable separately.
If cast application or strapping is provided as an initial procedure
in which no surgery is performed (e.g., casting of a sprained ankle
or knee, or open or closed treatment), use the appropriate level-ofoffice
visit in addition to the appropriate HCPCS code for the
casting supplies. The removal of an initial cast (in which no
surgery was performed) should be submitted as an office visit.
Incidental Surgery Blue Cross does not cover procedures that are incidental to other
major surgery and unrelated to illness, injury, or sterilization.
Incidental surgical procedures do not usually warrant separate
identification.
Lesions Certain CPT codes for the integumentary system indicate a second
or third lesion. Use these codes only with the primary code for the
first lesion. Use an office call code for treatment of wounds,
punctures, abrasions, and lacerations that do not require sutures or
debridement.
Surgical Trays and
Supplies
Codes 11400-11471, for removal of benign lesions such as
keratosis, cover a variety of techniques. The excision of benign
lesions with a laser is considered a variation of a surgical excision.
The dimension and location of the lesion should be recorded in the
operative report. Submit the appropriate code from the range listed
above.
No additional reimbursement will be made for surgical trays,
surgical or other miscellaneous supply codes A4550, A4649, and
99070. The allowance for these codes is considered bundled into
payment for the other services rendered.
Other supplies used in the office place of service are also generally
considered incidental or bundled into payment for any other
service performed.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (03/19/12)
11-5

Coding Policies and Guidelines (Surgical Services)
Implanted Supplies /
Devices
Supplies/devices implanted as part of the surgical procedure, are
considered integral to the procedure and are generally not
separately reimbursable.
Standby Services All standby services (code 99360), are not separately reimbursable.
Standby is considered incidental regardless of what is or is not
billed with that service.
Treatment of Warts The treatment of warts (verrucae, papillomas) via surgical or laser
excision is considered a variation of destruction of a benign lesion.
Use the CPT procedure codes 17000-17004.
Acne Treatment/Skin
Rejuvenation and
Rosacea Treatment
11-6
A cluster of warts is considered a single destruction of warts and
should be submitted using one unit of service.
Paring or curettement or shaving of warts with or without chemical
cauterization should be coded using CPT procedure codes 11055-
11057.
Electrocauterization or ‘‘burning off’’ of warts should be coded
using CPT procedure code 17110. This procedure code includes up
to 14 lesions. Fifteen or more lesions are coded as 17111. A cluster
of warts is considered a single operative procedure and should be
coded as such. Only one unit will be allowed for either code.
Blue Cross does not recognize the use of CPT procedure codes
11420-11446 for the treatment of warts. This range of codes is
considered for other types of skin lesions, such as a keratosis, etc.
The Blue Cross medical policy II-33, acne treatment/skin
rejuvenation details the policy on these treatments.
Blue Cross medical policy II-08, rosacea treatment details the
policy on these treatments.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (03/19/12)

Acne Treatment/ Skin
Rejuvenation and
Rosacea Treatment
(continued)
Anesthetic Agent
Injections
Coding Policies and Guidelines (Surgical Services)
The use of laser and light therapy, dermabrasion, chemical peels,
surgical debulking and electrosurgery to treat rosacea is
considered cosmetic and ineligible for reimbursement. The
treatment of telangiectasias is considered cosmetic and ineligible
for reimbursement.
Claim Audits
Routine claim audits have disclosed that some providers have been
submitting claims for therapies considered investigative, cosmetic
or not medically necessary for acne and rosacea treatment.
Adherence and Enforcement of Policy
Providers must abide by the requirements of all Medical Policies.
Blue Cross is taking action to enforce Medical Policies II-33 and
II-08 due to the volume of inappropriate claims. Claims will be
subject to retrospective review and denial, consistent with Medical
Policy. To view medical policies go to
providers.bluecrossmn.com and select then “medical policy”
under “tools & resources.”
Codes 64479-64484 indicate anesthetic agent injections in to the
levels of the spine. They should be billed per level and not per
injection. For example, a patient has an injection of the C2 and C3
bilaterally. The procedure should be coded as 64479-50 with one
unit. Two injections were given – one on the right and one on the
left; however, code 64479 represents cervical or thoracic, single
level.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (03/19/12)
11-7

Coding Policies and Guidelines (Surgical Services)
Intra-articular
Hyaluronan Injections
for Osteoarthritis
11-8
The Blue Cross medical policy II-29, intra-articularhyaluronan
injections for osteoarthritis states:
A course of three (3) to five (5) weekly injections of intra-articular
hyaluronan injections may be considered medically necessary for
the treatment of painful osteoarthritis of the knee in patients who
have insufficient pain relief from conservative nonpharmacologic
therapy and simple analgesics.
Repeated courses of intra-articular hyaluronan injections may be
considered medically necessary under both of the following
conditions:
Significant pain relief achieved with the prior course of
injections
At least six (6) months have passed since the prior course
The use of intra-articular hyaluronan injections into joints other
than the knee is considered investigative and not medically
necessary.
Coverage
Prior authorization is not required. However, services with specific
coverage criteria may be reviewed retrospectively to determine if
criteria are being met. Retrospective denial of claims may result if
criteria are not met.
The FDA-approved single dose injection of intra-articular
hyaluronan (i.e., Synvisc-One) may be used in lieu of the course of
three (3) to five (5) weekly injections when the medical policy
criteria stated above has been met.
Claim Audits
Routine claim audits have disclosed occurrences where some
providers have been submitting claims for therapies considered
investigative and not medically necessary.
Adherence and Enforcement of Policy
This is a reminder that providers must abide by the requirements of
all medical policies. Blue Cross is taking action to enforce Medical
Policy II-29. Claims for the use of intra-articular hyaluronan
injections into joints other than the knee will be subject to
retrospective review and denial as investigative services are not
eligible for reimbursement.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (03/19/12)

Liposuction Edit
Change
Coding Policies and Guidelines (Surgical Services)
Liposuction services, CPT® codes 15876-15879, are subject to
Blue Cross Medical Policy IV-82, which states that liposuction is
considered incidental when performed in conjunction with another
related primary surgical procedure. Liposuction is considered
investigative as a primary (i.e., stand-alone) procedure when the
usual treatment is surgical excision, or cosmetic as a primary
procedure in all other situations. The policy also stipulates that
“consideration for coverage will be given for the following rare
situation: Liposuction for treatment of painful lipomas in a person
with adiposis dolorosa that is unresponsive to analgesics.”
Regardless if the liposuction could be allowed per our medical
policy, we consider liposuction clinically integral to the outcome
of any related procedure and as such, should deny as incidental
when billed with other procedure codes.
Medical Policies
To view medical policies go to providers.bluecrossmn.com and
select “for health care providers” then “medical policy” under
“tools & resources.”
Incidental Coding Edit
An incidental coding edit was implemented for codes 15876-
15879. These services will deny to any other surgical procedure
code regardless of submission of the -59 modifier.
Patient Billing Impact
The patient is not responsible and must not be balance billed for
any procedures for which payment has been denied or reduced by
Blue Cross as the result of a coding edit. Edit denials are designed
to ensure appropriate coding and to assist in processing claims
accurately and consistently.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (03/19/12)
11-9

Coding Policies and Guidelines (Surgical Services)
Assistant Surgeons Almost all Blue Cross members have coverage for assistant
surgeon’s services when the following criteria are met:
11-10
The surgical assistant is a licensed physician, nurse practitioner
(NP), registered nurse first assistant (RNFA), or physician
assistant (PA).
The surgical assistant’s services are medically necessary. (This
is determined by the complexity of the surgery.)
Note: Assist at surgery services rendered by Surgical Techs or
Bachelor of Medicine and Bachelor of Surgery (MBBS)
practitioners are not allowable. Assistant surgery services rendered
by these specialties will be denied as an ineligible provider.
To bill services of an assistant surgeon (MD, NP, PA, or RNFA
acting as an assistant at surgery); use the surgical procedure code
with modifier -80.
The modifiers -81, 82 or –AS may also be used for assist services.
Modifier –AS specifically designates the assist as a physician
assistant, nurse practitioner or clinical nurse specialist.
If more than one surgical procedure was done during the same
session, list each procedure separately.
Generally, reimbursement for eligible assistant surgeon services is
16 percent of the surgery allowance. When an assistant surgeon is
involved in multiple surgical procedures, the same method used for
determining reimbursement for the primary surgeon shall be used
in determining reimbursement for the assistant surgeon. The
secondary surgeries will be subject to an additional multiple
surgery reduction (50 percent), if appropriate.
We do not publish a list of surgeries for which an assistant surgeon
is allowed. Generally, we follow the list that CMS has furnished to
Medicare carriers, for approved codes. However, we may subject
the assist services to additional edits or restrictions. Denied
assist-at surgery claims may be appealed with documentation. The
documentation/operative report should identify the assistant,
credentials, and should include the involvement, thus need, for the
assistant.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (03/19/12)

Assistant Surgeons
(continued)
Assist at surgery using robotics
Coding Policies and Guidelines (Surgical Services)
When a robot is used in conjunction with a surgery, an assist-atsurgery
service may be billed for a qualified practitioner (MD,
RNFA, NP, or PA) assisting by operating the machine (robot). The
appropriate surgical code and modifier would be billed. However,
separately billed charges for surgical robotics (S2900) will not be
allowed.
Co-Surgeons Co-surgery services are identified by use of the CPT modifier–62.
Co-surgery involves a surgical procedure report with a single
procedure code that requires two surgeons of different specialties
or a surgical procedure that involves two surgeons performing
parts of the procedure simultaneously. The additional surgeon is
not acting as an assistant at surgery (modifier –80 or –AS) or as
part of a surgical team (modifier –66).
Documentation must support the use of the –62 modifier. An
operative report(s) is required and will be requested if not
submitted.
Claims must be coordinated by the surgeons prior to filing their
claims. One operative report may be used, as long as both
surgeons’ responsibilities are identified. The following criteria
must be met:
Co-surgery services should be submitted using the appropriate
CPT surgical procedure code and the modifier -62. If more
than one modifier is being reported, list –62 first.
Both providers billing the -62 modifier should normally be
surgeons of different specialties. Examples would include
Gynecology/Urology, General Surgery/ENT, etc.
It must be medically necessary and an accepted standard of
care to have two surgeons of different specialties perform the
surgery.
Each surgeon must perform a distinct portion of the surgery.
Blue Cross follows Medicare’s guidelines regarding which
procedures will be reimbursed for co-surgery services. The
MPFSDB indicators are:
0= Co-surgeons not permitted for this procedure.
1= Co-surgeons may be paid if supporting documentation
is supplied to establish medical necessity.
2= Co-surgeons permitted.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (03/19/12)
11-11

Coding Policies and Guidelines (Surgical Services)
Co-Surgeons
(continued)
11-12
Allowable co-surgery services will be determined on a case-bycase
basis and upon review of supporting documentation.
Reimbursement will be 62.5 percent of the global surgery fee
schedule amount for allowable co-surgery services. Additionally,
global surgery rules will be applied to each of the physicians
participating in a co-surgery.
If multiple co-surgeries are submitted and allowed, the second or
subsequent surgery would also be subject to a multiple surgery
reduction, if the surgical code itself may be subject to a reduction.
For example, the first co-surgery would be allowed at 62.5 percent.
The second would be allowed at 62.5 percent then further reduced
by 50 percent.
If multiple co-surgeries are submitted and allowed, the second or
subsequent surgery would also be subject to a multiple surgery
reduction, if the surgical code itself may be subject to a reduction.
For example, the first co-surgery would be allowed at 62.5 percent.
The second would be allowed at 62.5 percent then further reduced
by 50 percent.
Multiple Surgeries When more than one surgical procedure is performed during the
same operative session, the -51 modifier may be appended to all
secondary surgical procedures; however, it is not necessary to
append this modifier. Applicable code edits will be applied to
services submitted. The -51 modifier itself does not affect
payment.
Payment for multiple surgeries is based on whether the surgical
procedure itself may be subject to a multiple surgery reduction. If
so, this reduction will be based on the highest allowed amount.
Multiple surgery reduction will be applied to the lesser allowed
procedure(s). Payment will be 50 percent of the allowed amount
for all covered secondary procedures.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (03/19/12)

Coding Policies and Guidelines (Surgical Services)
Co-Surgeons
(continued)
11-14
If multiple co-surgeries are submitted and allowed, the second or
subsequent surgery would also be subject to a multiple surgery
reduction, if the surgical code itself may be subject to a reduction.
For example, the first co-surgery would be allowed at 62.5 percent.
The second would be allowed at 62.5 percent then further reduced
by 50 percent.
If multiple co-surgeries are submitted and allowed, the second or
subsequent surgery would also be subject to a multiple surgery
reduction, if the surgical code itself may be subject to a reduction.
For example, the first co-surgery would be allowed at 62.5 percent.
The second would be allowed at 62.5 percent then further reduced
by 50 percent.
Multiple Surgeries When more than one surgical procedure is performed during the
same operative session, the -51 modifier may be appended to all
secondary surgical procedures; however, it is not necessary to
append this modifier. Applicable code edits will be applied to
services submitted. The -51 modifier itself does not affect
payment.
Payment for multiple surgeries is based on whether the surgical
procedure itself may be subject to a multiple surgery reduction. If
so, this reduction will be based on the billed amount. Multiple
surgery reduction will be applied to the lesser charge procedure(s).
Payment will be 50 percent of the allowed amount for all covered
secondary procedures.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (02/22/11)