Name of Manual - Blue Cross and Blue Shield of Minnesota

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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)
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Blue Cross and Blue Shield of Minne
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Recent Chapter changes: Chapter 11
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Chapter 11 - Coding Policies and Gu
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Durable Medical Equipment Date Topi
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Medical Emergency Date Topic Change
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Rehabilitative Services Date Topic
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Table of Contents Chapter 1 At Your
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Introduction Provider Policy and Pr
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How to Contact Us At Your Service P
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At Your Service Claims Address Subm
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Care Management Numbers and Address
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Care Management Numbers and Address
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Company Phone Number Address Public
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At Your Service Provider Identifica
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ID Cards At Your Service Introducti
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Electronic Commerce Overview An imp
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Remote Access Services (continued)
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Provider Communications Provider Co
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Health Plan Members have the Follow
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Provider Agreements Participation a
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Provider Agreements Responsibilitie
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Provider Agreements Provider Number
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Provider Agreements Accounting for
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Provider Agreements Carrier Replace
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Table of Contents Chapter 3 Quality
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Quality Improvement Leadership Rati
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Quality Improvement Telephone Care:
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Quality Improvement Quality of Care
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Quality Improvement Written Policie
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Quality Improvement Written Policie
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Quality Improvement Patient Safety
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Quality Improvement Medical Record
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Quality Improvement Institute for C
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Quality Improvement Quality Improve
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Quality Improvement Physical Facili
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Quality Improvement Treatment Recor
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Integrated Health Management Progra
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Integrated Health Management Provid
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Integrated Health Management Utiliz
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Integrated Health Management Medica
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Integrated Health Management Overvi
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Integrated Health Management Pre-Ce
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Integrated Health Management Decisi
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Integrated Health Management Defini
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Integrated Health Management For Lo
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Integrated Health Management Appeal
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Integrated Health Management Case &
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Integrated Health Management Diseas
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Integrated Health Management Focuse
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Integrated Health Management Specia
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Integrated Health Management Overvi
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Integrated Health Management Sample
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Health Care Options Prepaid Medical
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Health Care Options Member ID Cards
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Health Care Options Blue Cross and
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Health Care Options Double Gold Dou
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Health Care Options Medicare Basic
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Health Care Options Platinum Blue S
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Health Care Options MedicareBlue PP
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Health Care Options Inquiries and C
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Health Care Options Additional info
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Health Care Options Minnesota Senio
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Health Care Options MinnesotaCare P
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Health Care Options BlueLinkTPA Blu
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Health Care Options Delta Dental Hi
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Health Care Options Prime Therapeut
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Health Care Options Workers' Compen
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Health Care Options HICF 1500 Form
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Health Care Options Networks Blue C
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Blue Plus Member Information Introd
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Page 153 and 154: Blue Plus Member Benefits Members
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Page 157 and 158: Blue Plus Referral Points Remember
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Page 165 and 166: Blue Plus [Date] [Name of patient]
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Page 169 and 170: Blue Plus OB/GYN Open Access Diagno
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Page 173 and 174: BlueCard® Claim Status Inquiry ...
Page 175 and 176: BlueCard® Identifying BlueCard ®
Page 177 and 178: BlueCard® Identifying BlueCard ®
Page 179 and 180: BlueCard® BlueCard Service Claims
Page 181 and 182: BlueCard® Prior Authorization and
Page 183 and 184: BlueCard® Electronic Data Intercha
Page 185 and 186: BlueCard® Claims Processed by the
Page 187 and 188: BlueCard® Overview (continued) 3.
Page 189 and 190: BlueCard® Claim Payment Guidelines
Page 191 and 192: BlueCard® Calls from Members and O
Page 193 and 194: BlueCard® Guidelines (continued) W
Page 195 and 196: BlueCard® Types of Medicare Advant
Page 197 and 198: BlueCard® Medicare Advantage Claim
Page 199: BlueCard® Reimbursement for Medica
Page 203 and 204: Claims Filing Administrative Simpli
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Page 207 and 208: Claims Filing Claims with Coordinat
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Page 211 and 212: Claims Filing 1500 HICF Form Profes
Page 213 and 214: Claims Filing Ordering Forms and Ma
Page 215 and 216: Claims Filing Site of Service (cont
Page 217 and 218: Claims Filing Institution (837I) /F
Page 219 and 220: Claims Filing Treatment Room Blue C
Page 221 and 222: Claims Filing Single facility claim
Page 223 and 224: Claims Filing Present on Admission
Page 225 and 226: Claims Filing Medicare Crossover Bl
Page 227 and 228: Claims Filing Cancel/Void and Repla
Page 233 and 234: Claims Filing Verifying Patient Eli
Page 235 and 236: Claims Filing Basic Character Set V
Page 237 and 238: Claims Filing Rural Health Clinics
Page 239 and 240: Claims Filing Coordination of Benef
Page 241 and 242: Claims Filing TEFRA The 1982 Tax Eq
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Page 245 and 246: Claims Filing Surgical Technicians
Page 247 and 248: Reimbursement / Reconciliation Reim
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Reimbursement / Reconciliation Remi
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Reimbursement / Reconciliation Ques
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Reimbursement / Reconciliation Ques
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Reimbursement / Reconciliation Acco
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Reimbursement / Reconciliation Fiel
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Appeals Provider Appeals Introducti
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Appeals Submitting Requests for Pos
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Appeals Coding Appeals (continued)
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Appeals Supporting Documentation (c
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Coding Policies and Guidelines (Cod
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Chapter 11 Coding Policies and Guid
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Part-time (Medically Directed) Anes
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Electroconvulsive Treatments Blue C
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Moderate (Conscious) Sedation Monit
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Coding Policies and Guidelines (Beh
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Coding Restrictions Code Restrictio
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CTSS Skills Training and Developmen
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Intensive Residential Treatment Ser
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IRTS Member Eligibility IRTS Access
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Adult Non-Residential Crisis Servic
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MH-TCM Services to Minnesota Health
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Dialectical Behavioral Therapy/DBT
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Autism Spectrum Disorder/EIBI (cont
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Autism Spectrum Disorder/EIBI (cont
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Psychiatric Consultation to Primary
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Psychiatry and Chemical Dependency
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Medication Management M0064 and 908
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Nutritional Counseling/Medical Nutr
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Practitioner Key MD = Psychiatrist
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Clinical Supervision Under Minnesot
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DIAMOND Initiative (continued) Reim
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Missed Appointments (continued) Cou
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Guidelines for Court Ordered Evalua
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Guidelines for Court Ordered Evalua
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Behavioral Health Quality Improveme
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Coding Policies and Guidelines (Den
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Prior Authorization Requirements Co
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Coding Policies and Guidelines (Dur
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Waivers and Upgraded/Deluxe DME Wai
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Hearing Aids (continued) Website Co
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Portable Oxygen Billing (continued)
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DME/Supply Internet Purchases Codin
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Coding Policies and Guidelines (Hom
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Elderly Waiver Program (continued)
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Referrals and Prior Authorization (
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Referrals and Prior Authorization (
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Adult Day Care Bath Services Coding
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Home Infusion (continued) Coding Po
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Coding Policies and Guidelines (Hom
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Rules and Regulations (continued) H
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Hospice Billing for Medicare Produc
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Coding Policies and Guidelines (Hos
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Coding Policies and Guidelines (Lab
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Papanicolaou Smears (continued) Dia
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Coding Policies and Guidelines (Mat
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Coding Policies and Guidelines (Pha
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Drugs Coding Policies and Guideline
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Drug Programs Coding Policies and G
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Coding Policies and Guidelines (Pub
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Physical Therapy Evaluation Codes C
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Hot and Cold Pack Exclusion TMJ Ort
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Massage and Manual Therapy Exclusio
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MHCP PT, OT, ST Authorization Proce
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Bilateral Services (continued) Codi
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Coding Policies and Guidelines (Sur
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Acne Treatment/ Skin Rejuvenation a
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Liposuction Edit Change Coding Poli
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Assistant Surgeons (continued) Assi
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