7 Claims and Payment - Premera Blue Cross

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Premera Dental Reference Manual Premera Blue Cross Blue Shield of Alaska Section 1: Coding Resources Coding Types and Sources Current Dental Terminology (CDT) is a reference manual published every two years by the American Dental Association (ADA®). The CDT provides a listing of dental procedure codes, nomenclature and descriptors to help identify and report dental treatment performed by dentists. The CDT provides current and uniform dental terminology that provides an effective means for accurate nationwide communication among dentists, patients and third parties. You can order a CDT book by calling 800-947-4746 Coding We use HIPAA as the benchmark for accepting standard codes. Note: Since Premera cannot provide coding advice, we recommend that you maintain current copies of coding reference books in your office, or current versions of coding software. Deleted Codes We reimburse current effective procedure codes in the CPT book published by the American Medical Association in the year the service was rendered. If you submit a claim with a deleted code, it will be processed and the line item will indicate the corresponding denial code. Then, correct the claim to reflect the appropriate code and resubmit the claim as described in “Returned Claims”. Denied claims will be considered a provider write-off until the corrected claim is processed. Anti-fraud Premera abides by federal and state regulations concerning fraud, as well as our contract obligations to members and providers. Our mission is to provide peace of mind to our members about their healthcare coverage. To support our mission, we have a Special Investigations Unit (SIU) to prevent fraud and abuse. If you suspect fraud please call the Anti-Fraud Hotline at 800-848-0244. Important: We perform random audits to ensure services are billed appropriately. As part of the audit process, we may request dental records supporting use of these codes. Note: If billing under the medical benefit and need additional coding resources please refer to the American Medical Association (AMA) at 800-621-8335 or visit ama-assn.org. Claims and Payment Chapter 7 Page 2
Premera Dental Reference Manual Premera Blue Cross Blue Shield of Alaska Section 2: Claims Submission Member ID Number Provider Identification National Provider Identifier (NPI) When submitting claims, please transfer the member’s ID number exactly as it is printed on the ID card, including the leading three-character alpha prefix. The ID number must be used when submitting claims to identify the patient; Premera does not use the member’s social security number When completing the ADA® Dental Claim Form, please enter the following: Applicable Social Security number (SSN) or Tax Identification number (TIN) National Provider Identifier number (NPI) Treating dentist Billing dentist or dental entity The Department of Health and Human Services issued regulations about the NPI, which affect healthcare providers, payors (i.e., health plans), and healthcare clearinghouses. As part of HIPAA’s Administration Simplification provision, the NPI is a mandate requiring the adoption of a standard unique identifier for each covered healthcare provider (those that transmit healthcare information in an electronic form in connection with HIPAA standard claim transactions). The NPI replaces all proprietary (payor-issued) provider identifiers, including Medicare ID numbers (UPINs). It does not replace your tax ID number (TIN) or DEA number. TIN remains as a required element for claims. Electronic claims without a TIN are rejected as incomplete. If you have questions about NPI and electronic claims, email EDI@premera.com, or contact an EDI representative at 800-435-2715. Electronic Claims To speed claims turnaround, we urge you to submit electronically (see Section 11: Electronic Claims Submission for more information). If you submit claims electronically, refer to your electronic billing manual for specific formatting for electronic claims. Timely Claims Submission You can submit claims daily, weekly, or monthly. The earlier you submit claims, the earlier we process them. Ideally, we’d like you to submit claims within 60 calendar days of the covered services, but no later than 365 calendar days. Please refer to your contract for further claims submission information. For most plans, claims received more than 12 months after the date of service will be denied with NO member responsibility. Paper Claims If you are unable to submit claims electronically, you can submit paper claims on ADA® Dental Claim Forms. To speed claims processing, Premera uses document imaging and optical character recognition (OCR) equipment to “read” your claims. To ensure that OCR “reads” your paper claims accurately, here are some tips to help you: Submit using the most current ADA® claim form Submit appropriate supporting documentation when required Provide the members ID number in box 15 and box 8 if applicable (do not provide the member’s Social Security number) Type or print out ADA® claim forms in black ink (OCR equipment cannot read Claims and Payment Chapter 7 Page 3
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7 Claims and Payment - Premera Blue Cross

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