Name of Manual - Blue Cross and Blue Shield of Minnesota

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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)
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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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Blue Plus Member Rights and Respons
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Blue Plus Member Rights and Respons
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Blue Plus Member Benefits Members
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Blue Plus Quality of Care Complaint
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Blue Plus Referral Points Remember
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Blue Plus Referral Not Required We
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Blue Plus Standing Referral Minneso
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Blue Plus Clarifications of Terms (
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Blue Plus [Date] [Name of patient]
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Blue Plus Special Member Benefits O
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Blue Plus OB/GYN Open Access Diagno
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Blue Plus OB/GYN Open Access Diagno
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BlueCard® Claim Status Inquiry ...
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BlueCard® Identifying BlueCard ®
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BlueCard® Identifying BlueCard ®
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BlueCard® BlueCard Service Claims
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BlueCard® Prior Authorization and
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BlueCard® Electronic Data Intercha
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BlueCard® Claims Processed by the
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BlueCard® Overview (continued) 3.
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BlueCard® Claim Payment Guidelines
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BlueCard® Calls from Members and O
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BlueCard® Guidelines (continued) W
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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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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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Prior Authorization Requirements Co
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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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Elderly Waiver Program (continued)
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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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Hospice Billing for Medicare Produc
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Drug Programs Coding Policies and G
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Massage and Manual Therapy Exclusio
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Bilateral Services (continued) Codi
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Assistant Surgeons (continued) Assi
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