Your Quick Reference to Billing, Referrals, and e

Transcription

Your Quick Reference to Billing,
Referrals, and e-Connectivity
10/2007
All content current as of September 2007 unless otherwise indicated.
Independence Blue Cross offers products directly, through its subsidiaries Keystone Health Plan East and QCC insurance
Company, and with Highmark Blue Shield — independent licensees of the Blue Cross and Blue Shield Association.
Billing — Transactions
Table of Contents
Overview ................................................................................................................................. TR-4
Referrals and Authorization ..................................................................................................... TR-5
PCP Referrals to Participating Providers............................................................................... TR-5
PCP Referral Guidelines by Product ..................................................................................... TR-6
Authorizations .................................................................................................................... TR-8
Electronic Resources ............................................................................................................... TR-9
NaviNet® .......................................................................................................................... TR-9
Provider Interactive Voice Response (IVR) System ................................................................ TR-10
Procedure and Diagnosis Codes ........................................................................................... TR-15
Five-Digit Procedure Code Billing Requirement ................................................................. TR-15
Unlisted Procedures or Services .......................................................................................... TR-15
Pricing Procedure for Unlisted or NOC Services ................................................................. TR-16
Report Diagnosis Codes to the Highest Degree of Specificity .................................................. TR-16
Procedure and Diagnosis Code Update Release Schedules ..................................................... TR-17
ICD-9-CM Diagnosis Codes Change for Routine Gynecological Exams ................................ TR-17
Policy on the Use of Procedure and Diagnosis Codes ............................................................ TR-18
Copayments .......................................................................................................................... TR-20
Copayment Notification Requirement ................................................................................ TR-20
No Copayments or Coinsurance for Dual-Eligible Members (Keystone 65 Complete) ............. TR-20
Copayment Grids by Product ............................................................................................. TR-21
Claim Submission Requirements ........................................................................................... TR-26
Clean Claim Submission ................................................................................................... TR-26
Clean Claim Requirements ................................................................................................ TR-26
Submission of Claim Adjustments ...................................................................................... TR-27
Place of Service Codes ....................................................................................................... TR-28
National Provider Identifier (NPI)......................................................................................... TR-29
IBC’s Contingency Plan .................................................................................................... TR-29
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www.ibx.com/providers
TR-2
Paper Claims ......................................................................................................................... TR-30
CMS-1500 Form ............................................................................................................. TR-30
The CMS-1500 (08/05) Form and NPI ............................................................................ TR-30
Key Fields for the CMS-1500 (08/05) Form ...................................................................... TR-31
Claim Preprocessing .......................................................................................................... TR-31
Claims Submission Addresses ............................................................................................. TR-32
Electronic Claims Requirements............................................................................................ TR-33
Statement of Remittance (SOR) Enhancements ................................................................... TR-33
Online SOR ..................................................................................................................... TR-33
Clearinghouse Options for Electronic Claims Submission ..................................................... TR-33
HIPAA Compliance Testing and Conversion Instructions..................................................... TR-34
Claim Preprocessing .......................................................................................................... TR-34
Fee Schedule Inquiry ............................................................................................................. TR-36
Physician Claim Inquiry ........................................................................................................ TR-37
Physician Initial Claim Review Process .............................................................................. TR-37
Physician Claim Inquiry Form .......................................................................................... TR-38
Addendum A......................................................................................................................... TR-39
Addendum B ......................................................................................................................... TR-64
Addendum C ........................................................................................................................ TR-66
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Overview
The October 2007 issue of Transactions: Your Quick Reference to Billing, Referrals, and
e-Connectivity (Transactions) is designed to keep you and your office staff up to date on how to
do business with us by informing you of billing and Referral requirements and processing changes.
Transactions includes information on submitting clean claims, submitting proper codes used for
accurate disbursement, and NPI information and requirements. Additionally, Transactions contains
important information about electronic transaction channels, including clearinghouse options for
electronic claims submission and NaviNet®*, our secure provider portal, which accelerates processing
and payment.
Transactions has been designed as the Billing section of the Provider Manual for Participating
Professional Providers (Provider Manual), to be used as a quick reference by anyone in your office who
handles billing-related matters.
*NaviNet is a registered trademark of NaviMedix, Inc.
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Referrals and Authorization
Referrals are required for HMO and POS Members utilizing their in-network (referred) benefits.
One of the important functions Primary Care Physicians (PCPs) perform is coordinating the care an
HMO Member receives from a specialist. By coordinating Referrals, PCPs help to make the process
of patient care appropriate and continuous. Specialists must understand how to retrieve and verify
Referrals and Member eligibility information.
For PCPs, all Referrals should be submitted through NaviNet® or our Interactive Voice Response
(IVR) system. Specialists and facilities must receive PCP Referrals through NaviNet or the IVR
system. The IVR system for Referrals can be used from 5 a.m. until 10 p.m., 7 days a week by calling
1-866-681-7370. Submitting Referrals in a timely manner helps to prevent claim denials for “no
Referral.”
Because Referrals submitted through NaviNet and the IVR system are electronic, you are not
required to mail hard copies of Referrals to us.
Paper Referrals are no longer accepted for HMO/POS claims processing. All paper Referrals
submitted will be returned to the issuing provider. For specialists, NaviNet or the IVR system
should be checked to ensure that a Referral was received for a Member before services are rendered.
Specialists should no longer accept paper Referrals. A fax of an electronically submitted Referral may
be obtained by the specialist’s office via NaviNet or the IVR system.
While Covered Services should not be provided without the proper accompanying Referral, we
occasionally receive requests from providers for permission to resubmit a Referral or provide
corrected information to a Referral already submitted. In such instances, you no longer need to
contact us with this request.
If you need to amend information or resubmit a Referral, you may do so by submitting a new
Referral via NaviNet or the IVR system. These systems will accept Referrals up to 90 days prior to
the current date. Once a valid Referral has been received, you may request a claim review.
PCP Referrals to Participating Providers
Member Eligibility
All Participating Providers are required to verify Member eligibility through NaviNet® or the IVR
system.
Issuing Referrals to Participating Providers
• Services obtained without a Referral, when one is required under the Member’s benefits, will
not be covered by IBC.
• Services performed by non-Participating Providers require Preapproval. PCPs can locate
Participating Providers through our website, www.ibx.com, and through NaviNet.
• Referrals are valid for 90 days from date of issue.
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• PCPs no longer need to enter the number of visits for follow-up care. The provider to which
the Member is being referred will determine the number of visits medically appropriate for
the Member during the 90-day period for which the Referral is valid. In addition, if the PCP
selects the “evaluate and provide follow-up care as needed” box, the Member is authorized to
be seen by the specialist in an office or hospital setting.
• Referrals for facility/hospital admissions/surgical procedures: The PCP issues one Referral to
the specialist for hospital care; a separate Referral to the hospital is not required for hospital
admissions.
• Radiology Quality Initiative for HMO/POS Members: Ordering physicians/PCPs must issue a
Referral for all radiology services, including those that require Preauthorization. Radiology sites
must confirm this authorization prior to performing services.
• Providers should call the Care Management and Coordination Department at
215-241-2100 or 1-800-227-3116 to obtain Preapproval for required services.
• Admitting physicians are responsible for obtaining Preapproval at least five days prior to a
scheduled admission and notifying the facility of the Preapproval number. The hospital must
contact IBC prior to the admission to verify eligibility and the Preapproval number. All
pre-admission testing and hospital-based physician services (e.g., anesthesia) will be covered
under the hospital Preapproval.
• For PCPs in the five-county service area (Philadelphia, Delaware, Bucks, Chester, and
Montgomery counties), Members must be referred to capitated providers for podiatry,
physical therapy, and radiology services (except for Members covered under New Jersey plans).
Members must also be referred to capitated providers for laboratory services using requisition
forms supplied by the lab provider (except for Members covered under New Jersey plans).
Please see the Specialty Programs and Laboratory Services section of this manual for more
information.
PCP Referral Guidelines by Product
Keystone Health Plan East — HMO
• Members must select a PCP from the Keystone network.
• Referrals are required.
Products include:
• Keystone HMO
• Keystone HMO Flex Copay Series
• Keystone HMO Flex Deductible Series
• CHIP (Children’s Health Insurance Program)
• adultBasic
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Keystone POS
• Referrals are required for Members to receive the highest level of benefits.
Products include:
• Keystone POS
• Keystone POS Flex Copay Series
Keystone — Direct POS
• Referrals are required only for the following services:
– Podiatry*
– Routine radiology*
– Physical therapy*
– Spinal manipulations*
– Occupational therapy*
– Laboratory* — PCPs and specialists should continue to use the Lab requisition form
Members receive the highest level of benefits when they obtain Referrals for the services
noted above. For all other services, no Referrals are required.
Products include:
• Keystone — Direct POS Flex Copay Series
• Keystone — Direct POS Flex Deductible Series
*For capitated services, PCPs should refer Members to their designated sites. These services are capitated for PCPs in the
five-county area for these business lines.
Keystone 65 — Medicare Advantage HMO
• Members must select a PCP from the Keystone 65 network.
• Referrals are required.
The following products are not HMO products and do not require the Member to select a PCP and
do not require Referrals. However, Members receive the highest level of benefits when they seek care
from providers who participate in the IBC network.
• Traditional (Indemnity)
• Personal Choice®
®
• Personal Choice Flex Copay Series
• Personal Choice 65SM
®
• Personal Choice Deductible Series
• Security 65
®
• 65 Special
• Personal Choice HSA-qualified High
Deductible Health Plans (HDHP)
• Special Care
• Comprehensive Major Medical (CMM)/CompSelect®
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Certain services require Preapproval. IBC will not consider services for payment without the
necessary Preapproval.
Authorizations
Prior Authorization Criteria and Forms for Pharmacy-Related Services
Participating Providers, are required to use either NaviNet® or the FutureScripts® IVR system to
obtain prior authorization for pharmacy-related services for all Members. For a complete list of
pharmacy-related services that need prior authorization, please see the Pharmacy section of this
manual.
The FutureScripts IVR system can also be used to:
• have prior authorization forms faxed directly to your office;
• request a one-time 96-hour urgent fill;
• check the status of a prior authorization request;
• check the status of a direct-ship or Flex Series injectable request.
In addition, FutureScripts can be reached 24 hours a day, 7 days a week at 1-888-678-7012.
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Electronic Resources
NaviNet®
New technology is enabling today’s medical professionals to reduce time and costs associated with
the growing demands of health care administration. NaviNet, the HIPAA-compliant Web-based
connectivity solution offered by NaviMedix®, Inc., will increase efficiency and productivity in your
office.
With NaviNet access, you can connect with our back-end systems to streamline many of your daily
administrative tasks, thereby eliminating unnecessary telephone inquiries and plan transactions.
NaviNet benefits providers in many ways, including:
• Member Eligibility Search: After performing a Patient Search within the Referral Submission
feature, click on “View” to verify the Member’s Eligibility Details (including PCP name, PCP
effective date, and PCP-capitated site data) before proceeding to the Referral Request Form
for completion. This enhancement increases efficiency by eliminating your need to check
eligibility details separately using the Eligibility and Benefits feature. Also use the Referral
Inquiry feature to retrieve all NaviNet Referrals.
• Online Referrals: Specialists and facilities can receive Referrals from PCPs via their office fax
machine or via the NaviNet online Referral inquiry function. Because Referrals submitted
through NaviNet are electronic, you are not required to mail hard copies of NaviNet Referrals
to us.
• Auto-Fax Feature: Upon submission of Referrals, PCPs and OB/GYNs have the option to use
the NaviNet auto-fax feature to send the Referral directly to the specialist and/or facility via
fax. If preferred, PCPs and OB/GYNs can supply patients with a printed copy of the NaviNet
Referral for presentation to specialists and facilities. Specialists and facilities are required to
accept the NaviNet Referral form as a valid Referral, regardless of the method used for delivery.
• Required Information: If required information is omitted from the Referral, NaviNet will
prompt inclusion of any required information that is missing. Inclusion of information in
optional fields is recommended but not required to complete the Referral submission.
Investors in NaviMedix®, include an affiliate of IBC, which has a minority ownership interest in NaviMedix, Inc.
NaviNet Resources
For information on NaviNet® registration or questions, call the eBusiness Provider Hotline at
215-640-7410 or complete our Online Inquiry Form at www.ibx.com/providers/navinet.
Technical Assistance for existing NaviNet® users:
Call NaviMedix®, Inc. at 1-888-482-8057 8 a.m. to 8 p.m., EST, Monday through Friday, and
8 a.m. to 3 p.m., EST, Saturday.
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For assistance with testing and conversion to the HIPAA-compliant
claims transaction 837:
Call the NaviMedix, Inc. HIPAA Conversion Team at 1-866-877-6284. You may also contact the
IBC eBusiness Help Desk at 215-241-2305 or e-mail them at [email protected].
Provider Interactive Voice Response (IVR) System
You can use the IVR system, our speech-enabled, automated phone service, to retrieve Member
information and generate Referrals. To facilitate use of this new system, please refer to the following
pages for detailed information.
Provider IVR Menu Options
Once the call is connected, you will be prompted to make a selection from the IVR transaction
menu. You must select a transaction before entering your NPI or 10-digit group provider ID and the
last four digits of your tax ID.
The IVR transaction menu is as follows:
1. Member Eligibility/Benefits
2. Claims Status
3. Referral Submission
4. OB/GYN Referral Submission
5. Encounter Submission
6. Referral Inquiry
7. Authorization Status Inquiry
The IVR System Transactions: Step-by-Step Instructions
Voice prompts are provided throughout the call. Your responses may be spoken or entered through
your telephone keypad. When entering a code containing letters (e.g., HCPCS code), your response
must be spoken. Use the word “dot” for the decimal point. When entering a code with no letters,
your response may be spoken or entered via the telephone keypad using the star (*) key for the
decimal point. Press the pound (#) key to return to the Main Menu.
Note: The IVR system does not support behavioral health information. For information regarding
Behavioral Health, call Magellan Behavioral Health, Inc. at 1-800-688-1911.
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Menu Option 1 — Member Eligibility/Benefits
Step 1: Call 1-866-681-7370
Step 2: Select the corresponding menu option number 1 or say “Member Eligibility”
Step 3: Log in using your NPI or 10-digit group provider ID and the last four digits of your tax ID
Step 4: (Optional) Enter fax number to receive information via fax
Step 5: Enter valid Member ID (numeric only)
Step 6: Select Member
Step 7: To receive all Member eligibility information, say “all” or press the star (*) key. You can also
say “copay” for copay information only.
Menu Option 2 — Claims Status
Step 1: Call 1-866-681-7370
Step 2: Select the corresponding menu option number 2 or say “Claims Status”
Step 6: Enter the date of service
Step 7: Select claim for detailed information
Menu Option 3 — Referral Submission (available for HMO/POS PCPs
only)
Step 1: Call 1-866-681-7370
Step 2: Select the corresponding menu option number 3 or say “Referrals”
Step 5: Enter the service being requested
• Please speak from the available options:
– Allergy work up
– Fracture care
– Bony impacted tooth
– Dialysis
– Rehab (PT/OT/Hand)
– Evaluate/provide required follow-up inpatient/outpatient care for up to 90 days
Step 6: Enter the group provider ID where the Referral is being submitted
Step 7: Enter the Referral start date
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Step 8: (Optional) “Would you like to fax the Referral to the specialist’s office?”
Step 9: (Optional) “Enter the diagnosis code(s). Otherwise, please hold to receive the Referral
submission number.”
Note: You can press the star (*) key to correct a selection.
Menu Option 4 — OB/GYN Referral Submission (available for HMO/POS
PCPs only)
Step 1: Call 1-866-681-7370
Step 2: Select the corresponding menu option number 4 or say “OB/GYN”
Step 5: Enter the group provider ID where the Referral is being submitted
Step 6: Enter the service to be performed
• Please speak from the available options:
– Perinatal care
– Biophysical profile
– Endocrinology care
– Doppler flow study
– Ultrasound: General
– Fetal echocardiography
(normal pregnancy)
– Ultrasound: Targeted
– Amniocentesis
(high-risk pregnancy)
– Ultrasound: vaginal probe – Chorionic sampling (CVS)
– Genetic lab studies
– PUBS
– Genetic counseling
– RhoGAM®
– Glucose tolerance test
– Pelvic ultrasound
– Non-stress test
– Abdominal x-ray
– Contraction stress test
– IVP
Step 7: Enter the Referral start date
– Dexascan
– Hysterosalpingogram
– Fertility consult
– Genetics consult
– GI consult
– GYN oncologic consult
– Surgical consult
– Urologic consult
– Uro-gynecologic consult
Step 8: (Optional) “Would you like to fax the Referral to the specialist’s office?”
Step 9: (Optional) “Enter the diagnosis code(s). Otherwise, please hold to receive the Referral
submission number.”
Menu Option 5 — Encounter Submission (available for HMO/POS PCPs
only)
Step 1: Call 1-866-681-7370
Step 2: Select the corresponding menu option number 5 or say “Encounters”
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Step 5: Enter the date of service
Step 6: Enter the service code
Step 7: Enter the diagnosis code
Step 8: Enter the place of service
Menu Option 6 — Referral Inquiry
Step 1: Call 1-866-681-7370
Step 2: Select the corresponding menu option number 6 or say “Inquiry”
Step 4: Enter valid search
• Referral number
• Member ID (numeric only) and Referral start and end date
Step 5: “Is the requestor of the Referral asking about a Referral that was sent or received?”
(say “Sent” or “Received”)
Menu Option 7 — Authorization Status Inquiry
Step 1: Call 1-866-681-7370
Step 2: Select the corresponding menu option number 7 or say “Authorization”
Step 3: Log in using your NPI or 10-digit provider or group provider ID
Step 4: Enter the last four digits of your tax ID (numeric only)
Step 5: Enter valid Member ID number (numeric only)
Step 6: IVR will read back the Member ID number. To validate the Member ID, please respond by
pressing 1 for “Yes” (or by saying “Yes”) or 2 for “No” (or by saying “No”)
Step 7: IVR will read back the Member name and birth date
Step 8: To validate the Member name and birth date, please respond by pressing 1 for “Yes” (or by
saying “Yes”) or 2 for “No” (or by saying “No”)
Step 9: After the disclaimer is read, the most recent authorization request will be read by the IVR
Step 10: (Optional) “If you would like to hear this information repeated, press 1.”
Step 11: (Optional) “If any of the information for this authorization needs to be changed or
updated, press 2.”
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Step 12: (Optional) IVR will state: “Would you like to hear further authorization information for
this Member?”
• Please respond by pressing 1 for “Yes” (or by saying “Yes”) or 2 for “No” (or by saying
“No”)
– If “Yes,” IVR will ask you for a specific date of service or date range. Enter or speak the
date of service or date range when prompted. For example, to enter April 2, 2007, you
would enter 0-4-0-2-2-0-0-7. To speak the date of service or date range, you can speak
either “April two, two-thousand-seven,” or “four, two, zero-seven.” If a large number
of authorizations are retrieved as a result of your date input(s), you may be asked to
further narrow your search with a reference number or a procedure code.
– If “No,” IVR will ask you if you would like to hear authorization information for
another Member. Please respond by pressing 1 for “Yes” (or by saying “Yes”) or 2 for
“No” (or by saying “No”).
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Procedure and Diagnosis Codes
Five-Digit Procedure Code Billing Requirement
Procedures must be billed using the five-digit numeric CPT®* codes from the physician’s CPT
manual. Attachments or written descriptions of the service(s) being performed will not be considered
a proper billing procedure.
Supporting documentation in the Member’s medical report must clearly support the procedures,
services, and supplies coded on the health insurance form.
Note: Some CPT® codes may be included in global fees to facilities and therefore are not eligible for
separate reimbursement. You may bill the facility in those instances.
Unlisted Procedures or Services
Some services or procedures performed by health care professionals are not found in the CPT coding
system. They may be new procedures that have not yet been assigned a CPT code, or they may
simply be a variation of a procedure that precludes using the existing CPT code. Each section of the
CPT coding system includes codes for reporting these unlisted procedures. Unlisted procedure codes
should not be used unless a more specific code is not available. If a specific CPT code is not located,
check for HCPCS codes that may be reportable. Because unlisted procedure codes are subject to
manual medical review, processing may take longer than usual.
All unlisted/not otherwise classified (NOC) codes must be submitted with the appropriate narrative
description of the actual services rendered on the CMS-1500 claim form in order to be processed.
For claims that are electronically submitted, please refer to your HIPAA 837 Companion Guide. You
can connect to the Guide at our website, www.ibx.com/edi.
For paper-submitted claims, additional information regarding the narrative description of the specific
services provided should be submitted in the shaded area extending from field 24A through 24G,
directly above the NOC/unlisted procedure code on the CMS-1500 claim form. If a description
is not provided, the entire claim will be rejected with a message to resubmit with a narrative
description.
For electronically submitted 837P claims, the NOC descriptions should be populated in the 2400
loop and NTE segment using the Additional Information Qualifier “ADD.”
* CPT® (Current Procedural Terminology) is a copyright of the American Medical Association (AMA). All Rights Reserved.
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. CPT® is a trademark of the AMA.
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Pricing Procedure for Unlisted or NOC Services
This pricing and processing procedure for unlisted or NOC covered services is used for all products
covered under your provider agreement.
1. We maintain a database of historical pricing decisions for similar services previously reviewed
and priced by IBC. If available, an appropriate fee in this database may be used to price the
current claim.
2. If the database does not have pricing for the current claim, then the claim is reviewed by us
for a pricing decision. We may request that the provider submit additional information to
facilitate pricing the claim. The additional information requested may include, but is not
limited to, an operative report, a letter of Medical Necessity, an office note, and/or an actual
manufacturer’s invoice. Providers should submit additional information only if specifically
requested to do so by IBC. Upon being recommended for payment and processing, claims are
priced using our standard pricing methodology, which is designed to consider new procedures,
and are processed in accordance with applicable claim payment policies and exclusions and
limitations in benefit contracts.
3. Providers who disagree with a specific unlisted/NOC service pricing determination should
follow the normal appeals process described in the Appeals section of this manual.
Providers are reminded to always use the most appropriate codes when submitting claims. Claims
submitted as NOC codes when a valid CPT® or HCPCS code exists may be denied.
Report Diagnosis Codes to the Highest Degree of Specificity
We require that all practitioners report diagnosis codes to the highest degree of specificity, according
to the most current ICD-9-CM Coding Manual. This requirement applies to all claims and
encounters. It reflects:
1. The need for better diagnostic information for quality and medical management.
2. The decision to make our coding policy more consistent the other major carriers and with the
Centers for Medicare & Medicaid Services (CMS) ICD-9-CM coding guidelines.
3. The decision by CMS to determine Medicare Advantage premiums based on the severity of
illness of enrolled Members. Supporting documentation in the patient’s medical record must
clearly support the procedures, services, and supplies coded on the health insurance form.
The following are guidelines for diagnosis coding:
• Most ICD-9-CM codes require the fourth or fifth digits. There are only about 100 valid
three-digit codes.
• Most ICD-9-CM coding manuals include a color-coded system to designate diagnosis codes
that require additional digits beyond the basic three digits. Please refer to your
ICD-9-CM Coding Manual for specific instructions regarding the fourth or fifth digit.
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• Always include the fourth or fifth digit when indicated in the ICD-9-CM Coding Manual.
• Always report with the highest level of specificity possible for an individual patient.
Exceptions: The following providers are not required to report ICD-9-CM diagnosis codes to
the highest degree of specificity: home health agencies, independent laboratories, independent
physiological laboratories, general dentists, orthodontists, endodontists, pedodontists, pharmacies,
durable medical equipment suppliers, ambulance services, orthotic and prosthetic suppliers, and
home infusion providers.
Procedure and Diagnosis Code Update Release Schedules
Providers are required by the Health Insurance Portability and Accountability Act (HIPAA)
Transactions and Code Sets Rules to use only the CPT®, HCPCS, and/or ICD-9 codes that are valid
at the time a service is provided.
National entities, including American Medical Association, CMS, and the Department of Health
and Human Services release scheduled updates to CPT, HCPCS, and ICD-9 procedure/diagnosis
codes, respectively.
We monitor those schedules and react according to the following timeline (Note: Timeline reflects
schedule of entity and, therefore, may be subject to change):
• CPT® procedure codes: Biannual release of codes with effective dates of January 1 and July 1.
• HCPCS procedure codes: Quarterly release of codes with effective dates of January 1, April 1,
July 1, and October 1.
• ICD-9 procedure/diagnosis codes: Biannual release of codes with effective dates of April 1 and
October 1.
We no longer allow a 90-day grace period on deleted procedure and diagnosis codes. Therefore, the
provider must submit only the CPT, HCPCS, and/or ICD-9 codes that are valid at the time that a
service is provided.
ICD-9-CM Diagnosis Codes Change for Routine
Gynecological Exams
OB/GYNs and capitated PCPs billing above capitation for routine gynecological exams should
report diagnosis code V72.31 with the applicable preventive evaluation and management CPT
codes 99384-99387 and 99394-99397 or the HCPCS codes S0610 and S0612 for reimbursement
consideration. Do not bill both a preventive CPT and an annual gynecological exam HCPCS
code for the same date of service. Only one will be paid. Problem visits may be billed along with a
preventive service code for same date of service, if appropriate.
Routine gynecological exams reported with ICD-9-CM code V72.32 for the CPT codes
99384-99387 and 99394-99397 are no longer eligible for additional payment outside the standard
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capitation amount. HCPCS codes S0610 and S0612 may still be reported with ICD-9-CM code
V72.32 when appropriate.
For reference, the diagnosis code narratives are as follows:
• V72.31: Routine gynecological examination.
• V72.32: Encounter for Papanicolaou cervical smear to confirm findings of a recent normal
smear following initial abnormal smear.
Remember: We require all practitioners to report diagnosis codes to the highest degree of specificity,
according to the ICD-9-CM Coding Manual.
If you have questions, please call Provider Services or your Network Coordinator.
Policy on the Use of Procedure and Diagnosis Codes
Radiologic Guidance of a Procedure
We revised the reimbursement methodologies applied to claims processing of radiologic guidance
and/or supervision and interpretation of a procedure.
• Radiologic guidance and/or supervision and interpretation is performed by either the same
professional provider who performs the surgical procedure or a different professional provider.
• Radiologic guidance and/or supervision and interpretation of a procedure that is performed
in conjunction with a covered procedure is eligible for separate reimbursement consideration
by IBC.
When the same provider performs and reports both the radiologic and the diagnostic or therapeutic
procedures, both procedures are eligible for reimbursement consideration to the provider. However,
all of the following requirements must be met:
• Both the radiologic guidance and/or supervision and interpretation service and the procedure
for which it is performed must be covered for the radiologic guidance and/or supervision and
interpretation to be eligible for separate reimbursement consideration.
• Documentation in the medical record must reflect the radiologic guidance and/or supervision
and interpretation procedure(s) performed by the physician. The medical record must be
available to us upon request. Providers should not submit medical records to us unless
otherwise requested.
More information regarding our policy on Radiologic Guidance of a Procedure can be viewed online
at www.ibx.com/medpolicy.
Interrupted Maternity Care
Should you provide prenatal visits alone to any IBC Member, please bill those services as follows:
• If you provided a total of fewer than 4 visits
– First visit: Bill 99205 (new patient) or 99215 (established patient)
– 2nd and 3rd visits: Most 2nd and 3rd visits typically only require a level 3 office visit.
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Exclusively billing these visits at higher levels than Medically Necessary is not an
appropriate billing practice and is subject to post-payment review.
• If you provided a total of 4 – 6 visits, bill only 59425
• If you provided a total of 7 or more visits, bill only 59426
10/2007
TR-19
Copayments
Copayment Notification Requirement
A provider must notify a Member if the office provides the opportunity for the Member to
receive services and be billed from more than one entity. For example, the office must inform the
Member that he or she will be charged a copayment for the physician service and a copayment for
the ancillary service, such as radiology. If two services are billed on the same date of service, two
copayments may be required.
No Copayments or Coinsurance for Dual-Eligible Members
(Keystone 65 Complete)
In §1902(n) of the Social Security Act, dual-eligible Beneficiaries are excluded from cost-sharing. If a
provider does not currently participate with Medicaid, dual-eligible Keystone 65 Complete Members
are not responsible for cost-sharing and these Members may not be billed for copays, deductibles,
or coinsurance. If providers do participate with Medicaid, they can bill Medicaid for any applicable
reimbursement/payment.
To ensure that providers are able to identify these Members, the Members should be asked to show
their Keystone 65 Complete ID card and Medical Assistance Access identification cards. If the
Member’s Keystone 65 Complete ID card does show cost-sharing and the Member does not have a
Medical Assistance Access card, copayment or coinsurance may be billed to the Member.
10/2007
TR-20
Copayment Grids by Product
For copayment information, please refer to the following grids.
HMO/PPO Copayment Policy Summary (Non-Flex Benefits)
HMO Products
Keystone Health Plan East,
Keystone POS, Keystone 65,
Keystone 65 Direct POS,
Keystone Choice
(In-Network Services)
PPO Products
Personal Choice®
Personal Choice 65SM
Primary Care Office Visits
Subject to primary care office visit
copayment
copayment
Subject to specialist office visit
copayment
copayment
Subject to specialist copayment
Subject to restorative services
copayment
Subject to therapy copayment
At time of office visit
Copayment applies to office visit,
not the immunization
Provided without physician office
visit (administered by a nurse,
technician)
No copayment
No copayment
No copayment
No copayment
General Practice, Family Practice,
Internal Medicine, Pediatrics
Specialist Visits
Spinal Manipulation**
Copayment applies per visit and
not per individual service that is
provided during a single visit
Therapy Services**
Physical, Speech, Occupational,
Lymphedema, Orthoptic/Pleoptic,
Outpatient Cardiac Rehab; (For
HMO, copayment does not apply
to Outpatient Cardiac Rehab); one
copayment per date of service
Immunizations
Mammogram
Routine and Diagnostic
**For Keystone HMO/POS, most plan designs will not take a copayment for this procedure. Please refer to the Member’s
individual benefits for verification. For PPO products, these services are referred to as Restorative Services.
10/2007
TR-21
HMO Products
Keystone Choice
PPO Products
Personal Choice®
Outpatient Lab/Pathology
At time of physician office visit
not outpatient lab/pathology
Outpatient Facility and Lab
No copayment
No copayment
OB/GYN & Midwife
Routine GYN Visits
Non-Routine GYN Visit
and 1st Obstetrical Visit
Product
Copay
Type
Product
Copay
Type
Keystone
HMO/POS
Non-Flex
specialist
Personal Choice
Non-Flex
no copayment
Keystone 65
no copayment
for one Pap test
and one pelvic
exam every year
Keystone
HMO/POS
Non-Flex
specialist
Personal Choice
Non-Flex
specialist
Keystone 65
specialist
Personal Choice
65
specialist
no copayment
Personal Choice for one Pap test
65
and one pelvic
exam every year
Office-based Surgery
Copayment applies to the office
visit, not the surgery
Not subject to office visit
copayment within the postoperative
period determined by CMS
visit, not the allergy injections
technician)
No copayment
No copayment
Post-Surgical Office Visits
Allergy Injection
10/2007
TR-22
HMO Products
Keystone Choice
PPO Products
Personal Choice®
Standard Injectables
Administered by physician at time
of office visit
technician, etc.)
visit, not the injectable.
visit, not the injectable
Keystone 65 Injectables — refer to
Member’s benefits for applicable
copayment
Personal Choice 65 Injectables
— refer to Member’s benefits for
applicable copayment
No copayment
No copayment
Note: When the copayment is greater than the allowable amount, only the allowable amount should be collected from the
Member. In the event the copayment is collected and the practice subsequently determines the allowed amount is less than the
copayment, the difference between the allowable amount and the copayment for the service must be refunded to the Member.
The listing of copayments in this document is representative of standard benefits only. Please verify the Member’s specific benefit
package to determine all applicable copayments. This information does not apply to Personal Choice HSA-qualified HighDeductible Health Plan.
HMO/PPO Copayment Policy Summary (Flex Benefits)
HMO Products
Keystone HMO, Keystone POS,
Keystone Direct POS,
PPO Products
Personal Choice PPO
Office Visits
General Practice, Family Practice,
Internal Medicine, Pediatrics and
OB/GYNs
copayment
copayment
copayment
copayment
Specialist Visits
Spinal Manipulation
Copayment applies per visit and
not per service that is provided
during a single visit
10/2007
TR-23
HMO Products
PPO Products
Personal Choice PPO
Therapy Services
Physical, Speech, Occupational,
Lymphedema, Orthoptic/Pleoptic,
Outpatient Cardiac Rehab
Subject to therapy copayment
One copayment per date of service One copayment per date of service
Immunizations
At time of office visit
technician)
No copayment
No copayment
No copayment
No copayment
Outpatient Facility and Lab
No copayment
No copayment
Routine GYN Visits
Subject to primary care copayment
Non-Routine GYN Visit
and 1st Obstetrical Visit
Subsequent Obstetrical Visits
No copayment
No copayment
Mammogram
Routine and Diagnostic
Outpatient Lab/Pathology
OB/GYN visits
Office-based Surgery
Post-Surgical Office Visits
10/2007
TR-24
HMO Products
PPO Products
Personal Choice PPO
Allergy Injection
technician)
No copayment
No copayment
visit, not the injectable.
visit, not the injectable
Keystone 65 Injectables — refer to
Member’s benefits for applicable
copayment
Personal Choice 65 Injectables
— refer to Member’s benefits for
applicable copayment
technician, etc.)
No copayment
No copayment
Biotech/Specialty Injectables
Biotech/Specialty injectable
copayment applies
Biotech/Specialty injectable
copayment applies
Subject to office visit copayment
Subject to office visit copayment
Routine radiology copay applies
Routine radiology copay applies
Standard Injectables
Administered by physician at time
of office visit
Office-based or Self-Administered
Routine Radiology/X-Ray/
Diagnostic Services
One copayment per date of
Outpatient department of a
hospital or freestanding radiology service per product when multiple
services are billed
site
One copayment per date of
service per product when multiple
services are billed
Office setting
No copayment
No copayment
Emergency Room
No copayment
No copayment
Complex Radiology Services
Complex radiology copay applies Complex radiology copay applies
MRI/MRA, CT/CTA and PET
Scans
Outpatient department of a
hospital or freestanding radiology
site
Emergency Room
10/2007
No copayment
No copayment
TR-25
Claim Submission Requirements
Clean Claim Submission
A Clean Claim is one that does not require further information for processing. Incomplete and
inaccurate claims will be returned as non-Clean Claims. Returned claims are not necessarily a denial
of benefits, but arise from our need for accurate and complete information. Additionally, claims
that do not have adequate information to identify the billing provider can neither be processed nor
returned.
Clean Claims (both electronic and paper-submitted) must meet the following conditions:
• The service is a Covered Service by IBC Member’s group contract.
• The claim is submitted with all information requested by us on a claim form, or in other
instructions distributed to the provider.
• The person to whom the service was provided was covered by us on the date of service.
• We do not reasonably believe the claim was submitted fraudulently.
• The claim does not require special treatment. Special treatment means unusual claim
processing required to determine whether the service is covered.
Clean Claim Requirements
The following information must appear correctly for a claim to be considered clean:
• Group provider ID number*/NPI
• Rendering provider ID number/NPI
• Federal Tax ID number
• Billing address
• Member’s ID number (including applicable prefix and suffix)
• Member’s name
*Be sure the group provider ID number is associated with the Group Federal Tax ID number on file at IBC. Providers may
obtain this information via NaviNet® by using the Provider Change Form transaction to view current information on file at
IBC.
Member ID Numbers on ID Cards
As you may know, various states enacted laws to limit the use of a Member’s Social Security Number
(SSN) on ID cards and other materials. As a result of this legislative trend and to better protect
Member identity and privacy, we developed a unique Member ID for external communications to
Members, including all Member ID cards.
Please use the Member ID number when processing Member information. The Member ID number
consists of a 3-position alpha prefix, an 8-position ID number, and a 2-position suffix that defines a
10/2007
TR-26
member of the family unit. Traditional and CompSelect®/Comprehensive Major Medical (CMM)
Members have a 3-position alpha prefix and an 8-position ID number only.
To facilitate claims processing, please include the alpha prefix along with the complete Member ID
number as it appears on the Member’s ID card for all local and out-of-area claims. Previously, the
alpha prefix was required only on out-of-area claims. For HMO and POS, the lab indicator (for
example, “A,” “H,” “L,” “M,” “N,” “T,” or “Q”) located on the front of HMO and POS ID cards
should not be included in the Member’s ID number.
IBC rejects claims not billed with the complete Member ID. For timely and accurate claim payment,
the full Member ID must be billed as it appears on the ID card.
Provider ID Number Requirement
The rendering provider ID number must be recorded on all claims. This is a required data element
in conjunction with HIPAA compliance and other requirements. HMO, POS, and PPO claims
submitted without the ID number of the physician or other professional provider performing the
procedure or service are being rejected and returned as non-Clean Claims and must be resubmitted
with the necessary information.
Submission of Claim Adjustments
When submitting adjustment requests electronically to your Network Coordinator or our
Adjustment department using Microsoft® Excel or Access files, etc., please submit the following
fields:
IBC Claim ID Number
Performing Provider Name
Member ID
Modifier
Date of Service From
Modifier
Date of Service To
Modifier
Procedure/Service Code
Revenue Code
Patient Last Name
Units Billed
Patient First Name
Charged (billed) Amount
Patient Insured ID Number
Allowed Amount
Vendor (billing) Provider Number
Payment Amount
Vendor (billing) Provider Name
Expected Amount
Performing Provider Number
By submitting your adjustment requests with the fields listed above, we will be able to improve the
turn around time and maintain a higher level of service while processing the claim.
10/2007
TR-27
Place of Service Codes
Participating Providers are required to use the most up-to-date Place of Service codes on professional
claims to specify the entity where service(s) were rendered.
The most frequently submitted Place of Service codes are listed below. Always consult with your
vendor or practice management system contact to discuss payer specific changes to your system.
Place of Service Code
10/2007
Place of Service Name
11
Office
12
Home
21
Inpatient
22
Outpatient
23
Emergency Room — Hospital
24
Ambulatory Surgical Center
31
Skilled Nursing Facility
32
Nursing Facility
41
Ambulance — Land
42
Ambulance — Air or Water
65
End-Stage Renal Disease Treatment Facility
81
Independent Lab
TR-28
National Provider Identifier (NPI)
IBC’s Contingency Plan
In response to concerns over the health care industry’s state of readiness for the May 23, 2007,
National Provider Identifier (NPI) compliance date, the Centers for Medicare & Medicaid Services
(CMS) announced that through May 23, 2008, it will not impose penalties on covered entities that
deploy contingency plans to facilitate NPI compliance of their trading partners. CMS is encouraging
health plans to assess the readiness of their provider communities and determine the need to
implement contingency plans to maintain the processing of payments, while continuing to work
toward compliance.
Dual Use Claims Submission
Currently, IBC has the ability to accept claims with an NPI as the primary identifier if the provider
has registered their NPI with us.
However, providers must register their NPI with IBC prior to submitting NPI-only claims.
NPI-only claims will reject if the provider has not registered their NPI with us. To avoid any
potential business disruption for those providers who have not registered their NPI with IBC,
we have recommended a dual use strategy for claims submissions.
The dual use strategy allows providers to submit all electronic and paper claims with NPIs and
10-digit legacy provider identifiers (IBC-assigned IDs providers use to identify themselves as an IBC
participating health care provider). We will continue this dual use strategy until further notice while
continuing our provider outreach and testing efforts. If providers have registered their NPI with
IBC or submitted an NPI with a CMS certification, they may submit claims with their previously
registered NPI or may continue to submit claims with their NPI and 10-digit legacy identifier,
consistent with our dual use strategy, until further notice.
Our dual use strategy is intended to ensure that IBC is NPI compliant, but in a manner that
maintains operations, recognizes providers’ varying states of readiness, and avoids unnecessary
disruption in their cash flow.
Further information regarding NPI and how to bill using NPIs can be found throughout Transactions
and the Provider Manual for Participating Professional Providers.
10/2007
TR-29
Paper Claims
CMS-1500 Form
We currently utilize optical character recognition technology in processing claims; therefore,
for those claims that are paper-billed, please remember to use the standard red CMS-1500 form
to ensure accurate and timely processing. The following instructions explain how to facilitate
automated processing.
1. Please type clearly in specified areas only. Change ribbons often or use a laser printer. Do not
use red ink.
2. Do not use bold, italic, or other non-standard fonts.
3. Make sure the claim forms are complete and accurate. Extraneous writing on the form such as
“This is a second submission” will cause delays.
4. Do not use carbon copy forms because of the red transformation in the carbon.
5. Non-standard forms, such as black-and-white, dot matrix, handwritten, or laser-printed forms
will cause processing delays.
The National Uniform Claim Committee (NUCC) has released a revised 1500 Claim Form, which
is commonly referred to as the CMS-1500. The revised CMS-1500 (08/05) replaces the current
CMS-1500 (12/90).
We are currently accepting both 1500 claim forms. We will notify providers when they must
discontinue using CMS-1500 (12/90).
CMS-1500 (12/90) Form: This form does not accommodate use of the NPI; therefore, we suggest
using the revised CMS-1500 (08/05) form to support IBC’s Dual Use Claim Submission strategy.
CMS-1500 (08/05) Form: Providers may report NPIs on the CMS-1500 (08/05) form if the NPIs
have been registered with IBC. NPI-only claims will reject if the provider has not registered the NPI
with IBC. To avoid any potential business disruption for those providers who have not yet registered
their NPIs with IBC, we have recommended a dual use strategy for claims submissions. For more
information on Dual Use Claims Submission refer to page TR-29.
The CMS-1500 (08/05) Form and NPI
Revisions to the 1500 Claim Form include several fields that accommodate the use of your NPI.
A sample CMS-1500 (08/05) claim form has been included as Addendum B.
Though the CMS-1500 (08/05) claim form accommodates NPI, you may continue to report
10-digit legacy provider identifiers in the appropriate shaded areas of the form (17a, 24J, 32b, and
33b) until otherwise notified. A 10-digit provider identifier must be preceded by a two-character
qualifier ID. This qualifier ID is the same as the qualifier ID used when billing electronically. If you
do not currently bill electronically, please use the following ID: 1B.
10/2007
TR-30
Key Fields for the CMS-1500 (08/05) Form
Since the introduction of the revised CMS-1500 (08/05), we have received a significant number of
claims with incorrect information entered in key fields.
The revised CMS-1500 (08/05) cannot be completed in the same manner as its predecessor,
CMS-1500 (12/90), as many fields have been moved or changed. In addition, several new fields
have been added to the CMS-1500 (08/05) to accommodate NPI.
CMS-1500 (08/05) submissions populated with incorrect or incomplete information entered in key
fields may be rejected or returned to the provider.
The following key fields must be entered correctly on the CMS-1500 (08/05) to ensure timely and
accurate claims processing.
Highlighted fields are NPI-specific.
17a
Enter referring provider’s two-character qualifier ID (1B) in the first segment,
and referring provider’s legacy provider ID in the second segment.
17b
Enter referring provider’s NPI.
19
Enter ZZ qualifier ID and billing provider’s primary taxonomy code.
24I (shaded)
Enter rendering provider’s two-character qualifier ID (1B).
24J (shaded)
Enter rendering provider’s legacy provider ID.
24J (unshaded)
Enter rendering provider’s NPI.
32a
Enter service facility NPI.
32b
Enter service facility two-character qualifier ID (1B) and legacy provider ID.
33a
Enter billing provider NPI.
33b
Enter billing provider two-character qualifier ID (1B) and legacy provider ID.
Please contact your Network Coordinator if you have any questions about completing the
CMS-1500 (08/05) form and refer to the illustration in Addendum C for additional information.
Claim Preprocessing
Please see the additional information in Addendum A about the claims preprocessing enhancements
worksheet on ways to remedy rejected claims.
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TR-31
Claims Submission Addresses
Keystone Health Plan East – PA Provider Claims (Five-County)
Professional
P.O. Box 898815
Camp Hill, PA 17089-8815
Personal Choice® Claims
P.O. Box 890016
PA Provider Claims – Lehigh, Lancaster, Northampton, and Berks Counties
Independence Blue Cross
P.O. Box 69303
Harrisburg, PA 17106-9303
Professional Claims Inquiry
P.O. Box 7930
Philadelphia, PA 19101-7930
Comprehensive Major Medical
P.O. Box 890029
Magellan HMO/POS Claims
Magellan Behavioral Health, Inc.
P.O. Box 1958
Maryland Heights, MO 63043
Magellan Caring Foundations Claims
Magellan Behavioral Health, Inc.
P.O. Box 2185
Maryland Heights, MO 63043
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TR-32
Electronic Claims Requirements
Statement of Remittance (SOR) Enhancements
The paper SOR has been improved for adjusted claims, claims retraction, and credit balances. Some
of these revisions will affect the Electronic Remittance Advice (ERA).
When a claim is reversed and repaid, the adjusted claim number will now appear on the statement
below the claim number originally used to pay the claim. The adjusted claim number will also
appear in the ERA.
The ERA will show the original claim number in the CLP 07 and the adjusted claim number in
REF 02 within the 2100 Loop.
Please share this information with your billing staff and your software vendor. If you have any
questions, please contact your Network Coordinator or Provider Services.
Online SOR
You can use the NaviNet® SOR Inquiry transaction to view all the remittances issued to providers in
your group. SOR information can be viewed for a 13-month rolling calendar.
Online SORs have several advantages: You can search for specific SORs (by patient account number,
statement date, or statement number), obtain greater detail within individual remittances, and easily
obtain each claim’s summary and line-level detail.
Your office’s security officer can set the permission on NaviNet® by using the User Permissions
Manager Transaction. You can notify us that your office wants to view SORs online through NaviNet
SOR Registration. Once your registration has been processed, you will be able to review reports from
that date forward. Processing takes approximately five business days. The SOR data will be available
to view for a period of 13 months.
Clearinghouse Options for Electronic Claims Submission
Your software vendor may be contractually obligated to use a specific third-party clearinghouse
vendor for electronic submissions. That clearinghouse can assist you with testing to ensure that your
electronic claim submissions are seamless. Many clearinghouse options are available. The following
clearinghouses can all be used for electronic submissions in 837P:
• Datastream
• Quadramed
• SSI
• NDC
10/2007
TR-33
• Seimens (HDX)
• Web MD (Emdeon)
• McKesson
Most claim management systems are designed to work with your existing Practice Management
System.
HIPAA Compliance Testing and Conversion Instructions
For assistance with testing and conversion to the HIPAA-compliant claims transaction 837, please
contact the NaviMedix®, Inc. HIPAA Conversion Team at 1-866-877-6284. You can also contact the
IBC eBusiness Help Desk at 215-241-2305 or email at [email protected].
For providers who submit electronic claims through Highmark: If you have not yet converted to the
HIPAA-compliant 837 claims transaction, before being able to test for conversion you must complete
a new enrollment application at www.highmark.com/edi/signup/index.shtml.
Many clearinghouse vendors are also available to assist you with testing to ensure that your electronic
claim submissions are seamless. These include, but are not limited to, those on the list above.
Claim Preprocessing
Claim preprocessing is an initiative that allows NaviMedix®, Inc. to validate claim data that is critical
for claim processing and payment, prior to IBC receiving the claim.
We incorporated the HIPAA-compliant 837P transactions into the existing Claim Preprocessing
System (CPPS) for Keystone Health Plan East (KHPE) HMO, KHPE POS, Keystone 65, Personal
Choice®, and Personal Choice 65SM claims.
The benefits of claim preprocessing:
• Increased accuracy of claim processing and payment.
• Avoidance of payment delays due to missing or inaccurate data.
• Error reports that, when appropriate, provide data needed for error correction.
Types of claims preprocessed:
• All electronically submitted KHPE HMO, KHPE POS, Keystone 65, Personal Choice® and
Personal Choice 65SM claims in the ANSI X-12 HIPAA-compliant 4010A1 or 3051 format
with a 95056 or 54704 NAIC code.
• All KHPE HMO and POS claims billed via 1500 claim forms.
If you are having problems with claims rejecting, please read carefully the section below labeled
“Electronic Claim Submitters,”. This information will help you to submit claims successfully.
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TR-34
Claims Preprocessor Enhancements
Addendum A, on pages TR-39 – TR-63, includes a worksheet highlighting rules that will be applied
to claims and comments on how to remedy rejected claims. This worksheet will help you determine
why a claim was rejected and provide a basis for resubmitting a clean claim. This worksheet may
be updated to reflect new error codes and claim resolution instructions. It is intended to provide
guidance on current billing submission errors we have encountered.
When referencing the worksheet found in Addendum A, please keep in mind the following:
Column A contains current error rejections.
Column B contains the CPPS error code and the general description of why the claim was rejected
for both paper and electronic claim submissions.
Column C contains the error description reported on the Unsolicited 277 (U277) in data element
STC12 for electronic claim and the rejected claim report for paper claim submissions.
Column D contains U277 HIPAA Status and HIPAA Category codes for electronic claim
submissions only.
Column E contains the claim resolution instructions for 837P Loop/Data elements for electronic
claim submissions only.
Column F contains the claim resolution instructions for error resolutions for electronic claim
submissions.
Please note:
• Providers should continue to submit claims according to our guidelines.
• Provider claims will continue to be validated against the existing business rules.
Electronic Claim Submitters
If you submit claims electronically, you will continue to receive the U277 for notification of both
rejected and accepted claims. The error description on the U277 will aid you in correcting and
resending files to ensure an expedited remittance. In the worksheet, please pay special attention to
the columns that refer to electronic submissions: A, B, C, D, E, and F.
You can also refer to www.ibx.com/providers/self_service_tools or contact your Network Coordinator
for more information.
Please see Addendum A, the Claims Preprocessing Claims Edits Worksheet, on page TR-39.
10/2007
TR-35
Fee Schedule Inquiry
Fee schedule rates are available to all Participating Professional Providers, via a Fee Schedule Inquiry
Tool accessible through the NaviNet® portal. The fee schedule allowed amounts will reflect your
specific contract rates for your written contractual agreement with IBC.
This information provides you with online access to information about allowed amounts for
contractual procedures prior to claim and benefit adjudication, and therefore does not provide the
actual payment a provider may receive for a specific submitted claim. The Fee Schedule Inquiry Tool
does not include rates for capitated services or special contracting agreements.
All professional provider offices that have access to the NaviNet portal will have access to this
transaction through our Plan Central screens. Online instructions for use of this transaction are
available through NaviNet.
10/2007
TR-36
Physician Claim Inquiry
Physician Initial Claim Review Process
The Physician Claim Review process will consider HMO, POS, and PPO claims payment issues
concerning the application and correction of coding, claims logic, and other general issues related to
claims processing norms. To initiate the Physician Claim Review process, call Provider Services or
complete a Physician Claim Inquiry Form and send to:
Professional Claims Inquiry
P.O. Box 7930
Whether you call or complete a Physician Claim Inquiry Form, be sure to clearly identify the claims
issue and be prepared to provide any supporting documentation that will help explain your position.
If you are completing a Provider Claim Inquiry Form, please include the SOR. Physician Claim
Inquiry forms are available via www.ibx.com/providers/forms.
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TR-37
Reference#:
Date Submitted:
Pages Attached:
/
/
PHYSICIAN CLAIM INQUIRY FORM
Check here for inquiry type:
Amount of Payment Questioned
Rejection Questioned
Please follow these instructions carefully to ensure that your request is handled promptly and accurately.
Please mail completed form, Statement of Remittance, and supporting documentation to:
E
L
IBC Claims Inquiry
P.O. Box 7930
Member’s Plan:
Personal Choice® PPO
KS65/PC65
P
M
Practice Name
Other:
Provider Number
Name of Contact Person
Street Address
City
KHPE HMO
State
A
S
Member Name
Member ID
Claim Number
Date of Service
Zip
Telephone Number
(
)
Patient’s Name
Check Number
Date of Check or Explanation
Place of Service
Detailed Inquiry Reason:
If you have any questions, please contact Provider Services. Thank You.
HMO: 1-800-227-3119 PPO: 1-800-332-2566 Hours M-F 8AM - 5:30PM
IBC maintains processes to address and resolve provider inquiries and provider complaints related to the adjustment of claims. If you would like us to
investigate the way IBC has processed a particular claim, please complete this form and send it to us, along with the statement of remittance and any
supporting documentation to the address listed above.
We will investigate your claims-related issue, process any required adjustments, or send you a written resolution letter detailing the processing of the claim. If you
are dissatisfied with the results of our investigation you may file a provider appeal. Instructions for filing an appeal will be provided in the resolution letter. You may
also access our appeals process by following the instructions for appealing a claims determination posted on IBC’s website, www.ibx.com/providers/.
Independence Blue Cross offers products directly, through its subsidiaries Keystone Health Plan East and QCC Insurance Company, and with
Highmark Blue Shield — independent licensees of the Blue Cross and Blue Shield Association.
RETURN WITH REMITTANCE
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ALL
TRADES
IED PRINTING
UNION
LABEL
COUNCIL
13
SCRANTON
TR-38
Billing — Transactions — Addendum A
Addendum A
Claims Preprocessing Edits
Claims Resolution Document
10/2007
TR-39
10/2007
P0001b
P0002a
P0002b
Missing/Invalid HCPCS
Modifier Code
Missing/Invalid HCPCS
Modifier Code
3134
3134
P0001a
3001
Missing/Invalid Procedure
Code
Missing/Invalid Procedure
Code
3001
Description
CPPS
Error
Code
Modifier Code
Validation
Modifier Code
Validation
Procedure Code
Validation
Procedure Code
Validation
General
Description
B
A
Error
Code
New Pre-processor
Rejections
Current Error Rejections
A3
A3
A3
P0002a Modifier code ___ on service
line ___ is invalid. Please correct and
resubmit.
P0002b Modifier code ___ on service
line ___ is invalid for date of service
provided. Please correct and resubmit.
A3
122
122
122
122
A3
A3
A3
A3
453
453
454
454
STC01-1 STC01-2 STC10-1 STC10-2
Secondary Status
U277 Elements
D
U277 Details
Primary Status
U277 Elements
P0001b Procedure code ___ on
service line ___ is invalid for date of
service provided. Please correct and
resubmit.
P0001a Procedure code ___ on
service line ___ is invalid. Please
correct and resubmit.
Description Reported on the
• U277 - STC12
• Rejected Claim Report
C
New Error Descriptions
The procedure code modifier
submitted on the claim was
invalid. The provider must
resubmit the claim with a valid
procedure code modifier.
submitted on the claim was not
effective for the service line
date on the claim. The provider
must resubmit the claim with a
valid procedure code modifier
that is within the effective and
termination date of the procedure
code modifier.
2400.SV101-3, SV101-4,
SV101-5, or SV101-6
and date billed in 2400.
DTP03 when DTP01 =
472 (Service Line Date)
if DTP02 = RD8 (Range
of Dates) use first 8 bytes
must fall between the
modifier code effective and
termination dates.
The procedure code submitted
on the claim was not effective for
the service line date on the claim.
The provider must resubmit the
claim with a valid procedure code
termination date of the procedure
code.
2400.SV101-2 and date
billed in 2400.DTP03 when
DTP01 = 472 (Service
Line Date) if DTP02 = RD8
(Range of Dates) use first 8
bytes must fall between the
procedure code effective
and termination dates.
2400.SV101-3, SV101-4,
SV101-5, or SV101-6
The procedure code submitted
on the claim was invalid. The
provider must resubmit the claim
with a valid procedure code.
Error Resolutions
F
2400.SV101-2
837P Loop/Data
Element
E
Claim Resolution Instructions
TR-40
10/2007
P0004a
P0004b
Missing/Invalid Diagnosis
code
Missing/Invalid Diagnosis
code
N/A
3008
3008
N/A
A3
A3
A3
P0004a Diagnosis code ___ is
missing or invalid. Please correct
and resubmit.
P0004b Diagnosis code ___ is
missing or invalid ___ for date of
service provided. Please correct
and resubmit.
P0005 Charges ___ on service
line ___ exceeds $99,999.99.
Please correct and resubmit.
Diagnosis Code
Validation
Service Line
Charges Validation
Diagnosis Code
Validation
Procedure/Modifier
Code Validation
A3
A3
A3
A3
178
255
255
453
Claims Resolution Document
122
122
122
122
STC01-1 STC01-2 STC10-1 STC10-2
A3
• U277 - STC12
Secondary Status
U277 Elements
D
U277 Details
Primary Status
U277 Elements
P0003 Modifier ___ on service line ___
is not valid when billed with procedure
code ___; valid modifiers for this
procedure are___. Please correct and
resubmit.
General
Description
C
2400.SV102
The service line charge exceeds
$99,999.99. The provider must
resubmit the claim and split the
charges into 2 service lines.
The diagnosis code submitted
on the claim was not effective for
the service line date on the claim.
claim with a valid diagnosis code
termination date of the diagnosis
code.
2300. HI01-2 when HI01-1
= BK and 2300. HI02-2
– HI08-2 when HI02-1
– HI08-1 = BF and use
earliest date billed in 2400.
DTP03 when DTP01 =
472 (Service Line Date)
if DTP02 = RD8 (Range
of Dates) use first 8 bytes
must fall between the
diagnosis code effective
and termination dates.
submitted on the claim can not
be billed with the procedure code.
claim with a procedure code
modifier that is valid with the
procedure code submitted on
the claim.
Error Resolutions
F
on the claim was invalid. The
with a valid diagnosis code.
Addendum A
2300. HI01-2 when HI01-1
= BK and 2300. HI02-2
– HI08-1 = BF
2400.SV101-2 and
SV101-3, SV101-4,
SV101-5, or SV101-6
837P Loop/Data
Element
E
Claims Preprocessing Edits
P0005
P0003
N/A
N/A
Description
CPPS
Error
Code
B
A
Error
Code
New Pre-processor
Rejections
TR-41
10/2007
Billing Provider Tax ID
Validation
Billing Provider Number must
be 10 digits
be 10 digits
be 10 digits
P5{DC}
P0007
P5{DC}
Billing Provider Tax ID
Number Required
P0006
P12
Description
P0007b
P0007a
P0006
CPPS
Error
Code
P0007b The billing provider ID ___
you submitted is not valid. Please
correct and resubmit a valid billing
provider ID.
Billing Provider
Number must be
10 digits
Billing Provider
Number not valid
format
P0006 The billing provider tax ID
___ you submitted is not on file.
Please correct and resubmit a valid
billing provider tax ID.
• U277 - STC12
C
P0007a The billing provider ID
___ you submitted is not a 10
digit number. Please correct and
resubmit with your 10 digit billing
provider ID.
Billing Provider Tax
ID Validation
General
Description
B
A
Error
Code
New Pre-processor
Rejections
Secondary Status
U277 Elements
A3
A3
A3
122
122
122
A3
A3
A3
153
153
128
STC01-1 STC01-2 STC10-1 STC10-2
Primary Status
U277 Elements
D
U277 Details
2010AA.REF02 when
REF01 = 1A or 1B
2010AA.REF02 when
REF01 = 1A or 1B
2010AA.NM109 when
2010AA.NM108 equals 24
or 34 or
2010AA.REF02 when
2010AA.REF01 equals
EI or SY
837P Loop/Data
Element
E
The billing provider ID submitted
on the claim was not the valid
format. The provider must
resubmit the claim with a
valid provider ID. This edit is
applicable only to Personal
Choice and PC65.
The billing provider ID submitted
on the claim was not equal to
10 digits. The provider must
10-digit corporate ID number.
This edit is only applicable to
Keystone and Ancillary Facility
claims.
The billing provider tax ID
number submitted on the claim
is invalid. The provider must
resubmit the claim using a valid
tax ID number.
Error Resolutions
F
TR-42
10/2007
Billing Provider Number
Invalid
Validation
Rendering Provider Number
required
required
P0008
C2{DC}
P0009
N/A
P6{DC}
N/A
Description
P0009
P0008b
P0008a
CPPS
Error
Code
Rendering Provider
Number Required
Billing Provider
Number Validation
Billing Provider
Number Validation
General
Description
B
A
Error
Code
New Pre-processor
Rejections
P0009 Rendering provider ID
_____ on service line _____ is
required and was not received.
P0008b Billing provider ID _____
you submitted is not valid. Either
the number submitted is not on
file or the three-digit office location
suffix is incorrect. Please correct
and resubmit.
P0008a Billing provider NPI
_____ you submitted is not valid.
Either the number submitted
is not on file or the three-digit
office location suffix is incorrect.
• U277 - STC12
C
Secondary Status
U277 Elements
A3
A3
A3
122
122
122
A3
A3
A3
153
153
562
STC01-1 STC01-2 STC10-1 STC10-2
Primary Status
U277 Elements
D
U277 Details
2310B.REF or 2420A.REF
segment must exist
2010AA.REF02 when
REF01 = 1A or 1B
2010AA.NM109 when
2010AA.NM108 equals XX
837P Loop/Data
Element
E
The rendering provider ID was
not submitted on the claim. The
with a valid 10-digit corporate
ID number for Keystone and
Ancillary Facility claims or the
PBS number for PA PPO. We will
also accept the 10-digit corporate
ID on PA PPO.
The billing provider NPI
not valid. The provider must
10-digit corporate ID number for
claims or the PBS number for
PA PPO. We will also accept the
10-digit corporate ID on PA PPO.
claims or the PBS number for PA
PPO. We will also accept the 10
digit corporate ID on PA PPO.
Error Resolutions
F
TR-43
10/2007
N/A
must be 10 digits
P7{DC}
N/A
must be 10 digits
must be 10 digits
P0010
P7{DC}
Description
P0011
P0010b
P0010a
CPPS
Error
Code
A3
A3
P0010b Rendering provider ID ___
not valid format. Please correct
and resubmit a valid individual
provider ID.
P0011a Rendering provider NPI
_____ you submitted is not on file.
rendering provider ID.
Rendering Provider
Number not valid
format
Rendering Provider
Number Validation
A3
122
122
122
A3
A3
A3
153
153
153
STC01-1 STC01-2 STC10-1 STC10-2
Secondary Status
U277 Elements
D
U277 Details
Primary Status
U277 Elements
P0010a Rendering provider ID
___ you submitted is not a 10
digit number. Please correct
and resubmit with your 10 digit
• U277 - STC12
C
Individual Provider
Number must be
10 digits
General
Description
B
A
Error
Code
New Pre-processor
Rejections
2310B or 2420A NM109
when NM108 equals XX
2310B.REF02 or 2420A.
REF02 when REF01 = 1B
2310B.REF02 or 2420A.
837P Loop/Data
Element
E
The rendering provider ID
10-digit corporate ID on PA PPO
claims.
The rendering provider submitted
on the claim was not the valid
format. The provider must
provider ID. This edit is only
applicable to PA PPO.
equal to 10 digits. The provider
must resubmit with claim with
a valid 10-digit corporate ID
number for Keystone and
Ancillary Facility claims or the
PBS number for PA PPO. We will
also accept the 10-digit corporate
ID on PA PPO.
Error Resolutions
F
TR-44
10/2007
Validation
Tax ID does not match Billing
Provider Number
Billing Provider Number/Tax
ID Validation
Billing Provider Number/
Combo Validation
F04{DC}
P0012
P0013
Invalid
P0011
P8{DC}
Description
P0013
P0012
P0011
CPPS
Error
Code
P0012 Billing Provider Number
_______ - Tax ID _______
combination is NOT valid. Please
P0013 Billing Provider Number
_____ Rendering Provider Number
_____ on service line ____is NOT
valid. Please correct and resubmit.
Billing Provider
Number/Rendering
Provider Number
Combo Validation
P0011b Rendering provider ID
_____ you submitted is not on file.
• U277 - STC12
C
Billing Provider
Number/Tax ID
Validation
Rendering Provider
Number Validation
General
Description
B
A
Error
Code
New Pre-processor
Rejections
Secondary Status
U277 Elements
A3
A3
A3
122
122
122
A3
A3
A3
153
153
153
STC01-1 STC01-2 STC10-1 STC10-2
Primary Status
U277 Elements
D
U277 Details
Rendering Provider
Number - 2310B.REF02
or 2420A.REF02 when
REF01 = 1B
- 2010AA.REF02 when
REF01 = 1A or 1B
Tax ID - 2010AA.NM109
when 2010AA.NM108
equal 24 or 34 or 2010AA.
REF02 when 2010AA.
REF01 equals EI or SY
- 2010AA.REF02 when
REF01 =1A or 1B
2310B.REF02 or 2420A.
837P Loop/Data
Element
E
The rendering provider ID does
not match the billing provider
ID submitted on the claim. The
using an individual provider
number that matches the billing
provider number.
The rendering provider ID does
not match the billing provider tax
ID submitted on the claim. The
using a billing provider ID that
matches the tax ID.
10-digit corporate ID on PA PPO
claims.
Error Resolutions
F
TR-45
10/2007
U1{DC}
N/A
Invalid USI number was
submitted
N/A
Description
P0014b
P0014a
CPPS
Error
Code
P0014b:EE01 The Universal
identification number submitted
was not valid. Please submit the
full 13 character ID as it appears
on the patient’s card, without
spaces, hyphens, dashes, or other
special characters.
Invalid Alpha Prefix
Universal
Subscriber
Identification
Number Not Found
• U277 - STC12
C
P0014a:EE00 The first 3
characters in the member ID
number submitted were invalid.
Please submit the ID number
as it appears on the patient’s
identification card, without spaces,
hyphens, dashes, or other special
characters.
General
Description
B
A
Error
Code
New Pre-processor
Rejections
Secondary Status
U277 Elements
R1
R1
21
21
XO
XO
97
97
STC01-1 STC01-2 STC10-1 STC10-2
Primary Status
U277 Elements
D
U277 Details
2010BA.NM109 or
2010CA.NM109
2010BA.NM109 or
2010CA.NM109
837P Loop/Data
Element
E
The member ID submitted on the
claim was not valid. The provider
valid member ID.
The plan prefix submitted with
the member ID was invalid.
The provider should resubmit
the claim with the appropriate
member ID.
Error Resolutions
F
TR-46
10/2007
P0014c
P0014d
P0014e
No record of eligibility
based on submitted
member ID and/or
patient’s date of birth.
No record of eligibility
based on submitted
member ID and/or
patient’s date of birth.
No record of eligibility based
on submitted member ID
and/or patient’s date of birth.
4R{DC}
4R{DC}
4R{DC}
Description
CPPS
Error
Code
Member Not Found
based on Member
ID
Active Coverage
Not Found for
Date(s) of Service
Invalid Contract for
NAIC
General
Description
B
A
Error
Code
New Pre-processor
Rejections
E0
R1
R1
P0014d:EE03 Based on the
member ID number submitted,
the patient does not have active
coverage during the specified
date(s) of service.
P0014e:EE04 Based on the
member ID submitted, the patient
was not found. Please resubmit the
full ID as it appears on the patient’s
card, including alpha and numeric
characters, without spaces,
hyphens, dashes, or any special
characters.
21
21
116
XO
XO
N/A
97
97
N/A
STC01-1 STC01-2 STC10-1 STC10-2
Secondary Status
U277 Elements
D
U277 Details
Primary Status
U277 Elements
P0014c:EE02 Based on the
member ID number submitted,
the patient does not subscribe to
a product under the company you
submitted the claim to. Please
resubmit with a valid Member ID
for the company specified.
• U277 - STC12
C
2010BA.NM109 or
2010CA.NM109
2010BA.NM109 or
2010CA.NM109 and 2400.
DTP03 when DTP01 = 472
2010BA.NM109 or
2010CA.NM109 and
2010BB.NM109
837P Loop/Data
Element
E
valid member ID.
claim was not valid on the date of
service submitted on the claim.
claim with a valid member ID.
Note: If the provider/vendor is
submitting the claims through
Emdeon, the provider/vendor
should use the Emdeon payer
codes. Emdeon will convert the
payer codes to our NAIC codes.
• 95056 – KEYSTONE
• 54704 – PA PPO
claim was not valid based on the
NAIC code submitted. Please
resubmit the claim with the
appropriate NAIC code based on
the member’s coverage.
Error Resolutions
F
TR-47
10/2007
P0014f
P0014g
P0014h
4R{DC}
4R{DC}
4R{DC}
Description
CPPS
Error
Code
R1
R1
P0014g:EE06 Based on the
member ID and the patient Gender
submitted, the patient was not
found. Please resubmit the full
ID as it appears on the patient’s
ID card and the correct patient
gender.
P0014h:EK00 The format of the
patient’s IBC/Keystone member ID
is invalid. Please resubmit the full
ID as it appears on the patient’s
hyphens, dashes, or special
characters.
Member Not Found
based on Member
ID and Gender
Invalid IBC/
Keystone Patient ID
Submitted
Member Not Found
based on Member
ID and Date of Birth
21
21
21
XO
XO
XO
97
97
97
STC01-1 STC01-2 STC10-1 STC10-2
Secondary Status
U277 Elements
D
U277 Details
Primary Status
U277 Elements
R1
• U277 - STC12
C
P0014f:EE05 Based on the
member ID and the patient Date
of Birth submitted, the patient was
not found. Please resubmit the full
ID as it appears on the patient’s ID
card and the correct patient date
of birth.
General
Description
B
A
Error
Code
New Pre-processor
Rejections
2010BA.NM109 or
2010CA.NM109
2010BA.NM109 or
2010CA.NM109 and
2010BA.DMG03 or
2010CA.DMG03
2010BA.NM109 or
2010CA.NM109 and
2010BA.DMG02 or
2010CA.DMG02
837P Loop/Data
Element
E
valid member ID.
The member ID submitted on
the claim was not valid based on
the gender of the patient. The
with a valid member ID.
The member ID submitted on
the claim was not valid based on
the patient’s date of birth. The
with a valid member ID.
Error Resolutions
F
TR-48
10/2007
P0014i
P0014j
P0014k
Invalid USI number was
submitted
U1{DC}
4R{DC}
4R{DC}
Description
CPPS
Error
Code
R1
R1
R1
P0014j:EK02 The IBC/Keystone ID
number submitted was not valid.
Please submit the ID as it appears
on the patient’s card, including
alpha and numeric characters,
without spaces, hyphens, dashes,
or any other special characters.
P0014k:EK03 The IBC/Keystone
ID number submitted was not
valid. Please submit the full ID
hyphens, dashes, or any other
special characters.
Invalid IBC/
Keystone Patient
Identification
Number Format
Submitted
Invalid IBC/
Keystone Patient
Identification
Number Format
Submitted
21
21
21
XO
XO
XO
97
97
97
STC01-1 STC01-2 STC10-1 STC10-2
Secondary Status
U277 Elements
D
U277 Details
Primary Status
U277 Elements
P0014i:EK01 The Universal
IBC/Keystone ID submitted was
invalid. Please submit full 13
character ID as it appears on the
patient’s card, including alpha
and numeric characters, without
spaces, hyphens, dashes, or
special characters.
• U277 - STC12
C
Invalid
IBC/Keystone
Universal Patient
Identification
Number Format
Submitted
General
Description
B
A
Error
Code
New Pre-processor
Rejections
2010BA.NM109 or
2010CA.NM109
2010BA.NM109 or
2010CA.NM109
2010BA.NM109 or
2010CA.NM109
837P Loop/Data
Element
E
valid member ID.
valid member ID.
valid member ID as it appears on
the card.
Error Resolutions
F
TR-49
10/2007
P0014l
P0014m
P0014u
4R{DC}
4R{DC}
4R{DC}
Description
CPPS
Error
Code
R1
E0
R1
P0014m:EK06 The Patient
identification number submitted
is not on file at Independence
Blue Cross. Please resubmit with
a valid IBC/Keystone Member
ID or contact your submitter or
clearinghouse to correctly submit
the claim.
P0014u:EK05 The IBC/Keystone
Member ID submitted was not
special characters.
IBC/Keystone
Patient
Identification
Number Submitted
not an IBC/KHPE
member
Invalid
IBC/Keystone
SSN Patient
Identification
Number Format
Submitted
21
116
21
XO
XO
97
97
STC01-1 STC01-2 STC10-1 STC10-2
Secondary Status
U277 Elements
D
U277 Details
Primary Status
U277 Elements
P0014l:EK04 The IBC/Keystone
Patient SSN submitted was not
special characters.
• U277 - STC12
C
Invalid
IBC/Keystone
SSN Patient
Identification
Number Format
Submitted
General
Description
B
A
Error
Code
New Pre-processor
Rejections
2010BA.NM109 or
2010CA.NM109
2010BA.NM109 or
2010CA.NM109
2010BA.NM109 or
2010CA.NM109
837P Loop/Data
Element
E
valid member ID.
valid member ID.
The member SSN submitted
on the claim was not valid. The
with a valid member ID as it
appears on the card.
Error Resolutions
F
TR-50
10/2007
P0015
P0016b
Missing/Invalid NAIC (2010,
NM109)
Missing Adjustment Data
(2300, NTE01)
4R{DC}
3102
3114
P0014ac
Description
CPPS
Error
Code
Missing Adjustment
Note Description
Payer NAIC Code
Validation
Based on the
Member ID, the
claim should
be submitted to
Highmark
General
Description
B
A
Error
Code
New Pre-processor
Rejections
A3
A3
P0016b When CLM05-3 is
populated with 6, 7 or 8 indicating
an adjustment request, the claim
note segment is required. Please
R1
122
122
21
N/A
A3
XO
N/A
153
97
STC01-1 STC01-2 STC10-1 STC10-2
Secondary Status
U277 Elements
D
U277 Details
Primary Status
U277 Elements
P0015 The payer code ___ you
submitted is missing or invalid.
P0014ac: EE07 Based on the
submitted Member ID, the claim
should be processed at Highmark.
Please resubmit the claim to
Highmark for processing.
• U277 - STC12
C
2300.NTE
2010BC.NM109
2010BA.NM109 or
2010CA.NM109
837P Loop/Data
Element
E
The claim note is required
when CLM05-3 equals 6, 7,
or 8 because this indicates an
adjustment request. The provider
must resubmit the claim with the
claim note. NTE01 must equal
ADD and NTE01 must provide
details explaining why the claim
must be adjusted.
Note: If the provider/vendor is
submitting the claims through
Emdeon, the provider/vendor
should use the Emdeon payer
codes. Emdeon will convert the
payer codes to our NAIC codes.
• 95056 – KEYSTONE
• 54704 – PA PPO
The NAIC code submitted on the
claim is not valid for IBC. The
with the appropriate NAIC code
that is applicable to the LOB
submitted on the claim.
The submitted member ID
suggests that the claim should be
processed at Highmark. Please
resubmit the claim to Highmark.
Error Resolutions
F
TR-51
10/2007
P0017
P0018
P0019
P0020
Missing/Invalid Claim Filing
Indicator
Missing/Invalid Place of
Service
Missing/Invalid Place of
Service
Missing/Invalid Claim
Frequency Type Code
3219
3007
3007
3006
Description
CPPS
Error
Code
A3
A3
A3
P0018 The place of service ___
on service line ___ is missing or
invalid. Please correct and
resubmit the claim.
P0019 The facility type code ___ is
missing or invalid. Please correct
and resubmit.
P0020 The claim frequency type
code ___ is missing or invalid.
Place of Service
Code Validation
Facility Type Code
Validation
Claim Frequency
Code Validation
Claim Filing
Indicator Validation
122
122
122
122
A3
A3
A3
N/A
535
249
249
N/A
STC01-1 STC01-2 STC10-1 STC10-2
Secondary Status
U277 Elements
D
U277 Details
Primary Status
U277 Elements
A3
• U277 - STC12
C
P0017 Claim Filing Indicator ___ is
invalid. Valid claim filing indicators
are BL and CI. Please correct and
resubmit.
General
Description
B
A
Error
Code
New Pre-processor
Rejections
2300.CLM05-3
2300.CLM05-1
2400.SV105
2000B.SBR09
837P Loop/Data
Element
E
The claim frequency type code
on the claim is invalid. The
with a valid claim frequency type
code.
The facility type code on the
claim is invalid. The provider
valid place of service code. The
facility type code is the same as
the place of service code.
The place of service code on
the claim is invalid. The provider
valid place of service code.
The appropriate indicator is BL
for IBC or Keystone claims.
The claim filing indicator on the
claim is not valid when submitting
an IBC claim. The provider must
submit the appropriate indicator.
Error Resolutions
F
TR-52
10/2007
P0022
P0023a
P0023b
Data is required in Box 32
to process the claim
Submitted number in Box
32 is not 10-digit Corporate
ID
C3{DC}
G1{DC}
P0021
Multiple units not
appropriate with modifier
50
Unit count required
3242
U5{DC}
Description
CPPS
Error
Code
A3
A3
P0023a The service facility name,
address and provider ID is required
to process the claim. Please
P0023b The service facility
provider ID ___ you submitted is
not 10 digit number. Please correct
and resubmit with your 10 digit
service facility provider ID.
Global Radiology
and Laboratory
Service Facility
- Missing Facility
Information
Global Radiology
and Laboratory
Service Facility
- Invalid Facility
Number
A3
A3
122
122
122
122
A3
A3
A3
A3
153
153
476
476
STC01-1 STC01-2 STC10-1 STC10-2
Secondary Status
U277 Elements
D
U277 Details
Primary Status
U277 Elements
P0022 Multiple units ___ not
allowed with this modifier ___.
P0021 Unit field is null or zero ___
for service line ___. Please correct
and resubmit.
• U277 - STC12
C
Procedure Code
Modifier units
validation
Unit Field Validation
General
Description
B
A
Error
Code
New Pre-processor
Rejections
2310D.REF02
2310D
2400.SV101-3, SV101-4,
SV101-5 or SV101-6 equal
“50” and 2400.SV104 is
greater than “1”
The service facility provider ID
equal to 10 digits. The provider
must resubmit the claim with
a valid 10-digit corporate ID
number.
The provider did not submit the
service facility name, address,
or provider ID. The provider
appropriate information.
The provider submitted an invalid
unit count with the submission of
modifier “50.” The only allowable
unit count is “1.” Provider must
appropriate values.
2400.SV104
Error Resolutions
F
The unit(s) submitted on the
service line is invalid; zero is not
an allowable value. The provider
valid unit count.
837P Loop/Data
Element
E
TR-53
10/2007
P0023c
P0023e
P0024a
Submitted facility number in
Box 32 is not valid
Submitted number in Box 32
is not valid provider number
for reported services
Submitted facility number in
Box 32 is not valid
G3{DC}
G2{DC}
C3{DC}
Description
CPPS
Error
Code
P0023c The service facility
provider ID ___ is invalid. Please
P0023e The service facility
provider ID ___ is not valid for
reported services. Please correct
and resubmit.
P0024a The service facility name,
address and provider ID is required
to process the claim. Please
Global Radiology
and Laboratory
Service Facility
- Facility invalid for
reported services
RAP Service
Facility &
Unidentified
Provider - Missing
Facility information
• U277 - STC12
C
Global Radiology
and Laboratory
Service Facility
- Invalid Facility
Number
General
Description
B
A
Error
Code
New Pre-processor
Rejections
Secondary Status
U277 Elements
A3
A3
A3
122
122
122
A3
A3
A3
153
153
153
STC01-1 STC01-2 STC10-1 STC10-2
Primary Status
U277 Elements
D
U277 Details
2310D/REF02
2310D.REF02
2310D.REF02
837P Loop/Data
Element
E
The provider did not submit the
service facility name, address,
or provider ID. The provider
The service facility provider
ID submitted on the claim was
invalid for services submitted.
claim with the appropriate service
facility provider ID.
appropriate service facility
provider ID.
Error Resolutions
F
TR-54
10/2007
P0024b
P0025
P0026a
Data is required in Box 32 to
process the claim
Missing/Invalid Billing
Provider Secondary
Reference Number (2010AA,
REF segment)
Provider Secondary
Reference Qualifier
(2010AA, REF01)
C3{DC}
3235
N/A
Description
CPPS
Error
Code
Invalid Billing
Provider Number
Qualifier
Missing Billing
Provider Secondary
Identification
Number
RAP Service
Facility &
Unidentified
Provider - Invalid
Facility Number
General
Description
B
A
Error
Code
New Pre-processor
Rejections
A3
A3
A3
P0025 The billing provider
secondary reference number
is missing. Please correct and
resubmit.
P0026a Billing Provider Tax ID
_____ is required and was not
received. Please correct and
resubmit.
122
122
122
A3
A3
A3
128
153
153
STC01-1 STC01-2 STC10-1 STC10-2
Secondary Status
U277 Elements
D
U277 Details
Primary Status
U277 Elements
P0024b The service facility
provider ID ___ is invalid. Please
• U277 - STC12
C
2010AA.REF01 does not
equal EI or SY
2010.REF
2310D
837P Loop/Data
Element
E
EI - Employer’s Identification Number
SY - Social Security Number
The provider submitted a qualifier
that is not recognized by IBC
as being a billing provider Tax
ID number. The provider must
appropriate qualifier.
The provider did not submit
the billing provider secondary
reference segment. The billing
provider secondary reference
segment should contain the
provider’s IBC billing provider
number. The provider must
appropriate service facility
provider ID.
Error Resolutions
F
TR-55
10/2007
3243
SD{DC}
3236
P0026b
P0027
P0029
Provider Secondary
Reference Qualifier
(2010AA, REF01)
Diagnosis code not to the
highest specificity level
Claim sent to IBC in error,
Please submit claim to
Keystone Mercy Health Plan
Description
CPPS
Error
Code
A3
A3
P0027a The diagnosis code
___ not billed at highest level
of specificity. Please correct and
resubmit.
P0029 Claim sent to IBC in error,
please submit claim directly to
Keystone Mercy.
Diagnosis code not
billed at highest
level of specificity
Submit claim to
Keystone Mercy
Health Plan
A3
28
122
122
N/A
A3
A3
N/A
255
153
STC01-1 STC01-2 STC10-1 STC10-2
Secondary Status
U277 Elements
D
U277 Details
Primary Status
U277 Elements
P0026b The Billing Provider
secondary reference qualifier
is invalid. Please correct and
resubmit.
• U277 - STC12
C
Invalid Billing
Provider Number
Qualifier
General
Description
B
A
Error
Code
New Pre-processor
Rejections
2010BA.NM109 or
2010CA.NM109 and AMT
when AMT01 = F5
2300. HI01-2 when HI01-1
= BK and 2300. HI02-2
– HI08-1 = BF
2010AA.REF01 does not
equal 1A or 1B
837P Loop/Data
Element
E
The Keystone Mercy Health Plan
OOA claims must be submitted
to IBC as secondary, and prior
payments from the prior carrier
must exist on the claim.
on the claim was not at the
highest level of specificity. There
is a diagnosis code that is more
specific. The provider must
diagnosis code.
1A = IBC/Keystone
1B = IBC/Keystone
The provider submitted a qualifier
that is not recognized by IBC.
The provider must resubmit
the claim with the appropriate
qualifier.
Error Resolutions
F
TR-56
10/2007
Invalid Date
Invalid Date
3241
P0032b
P0032a
P0031
Not eligible for processing.
Resubmit to Local Plan
NC{DC}
3241
P0030
Not eligible for processing.
Resubmit to Local Plan.
NC{DC}
Description
CPPS
Error
Code
A3
A3
A3
A3
P0031 Claim is not eligible for
processing. Please resubmit
to local plan via the BlueCard
program.
P0032a The subscriber date of
birth ___ is either after the file
creation date or prior to 1900.
P0032b The patient date of birth
___ is either after the file creation
date or prior to 1900. Please
Non-Contiguous
Professional Claim
Edit
Invalid Subscriber
Date of Birth
Invalid Patient Date
of Birth
122
122
122
122
A3
A3
A3
A3
510
510
153
153
STC01-1 STC01-2 STC10-1 STC10-2
Secondary Status
U277 Elements
D
U277 Details
Primary Status
U277 Elements
Non-Contiguous
Ancillary Edit
• U277 - STC12
C
P0030 Claim is not eligible for
processing. Please resubmit
to local plan via the BlueCard
program.
General
Description
B
A
Error
Code
New Pre-processor
Rejections
2010CA.DMG02
2010BA.DMG02
2010AA.REF02 when
REF01 = 1A or 1B
2010AA.REF02 when
REF01 = 1A or 1B
837P Loop/Data
Element
E
date. The date is either after the
GS04 (file creation date) or the
year was on or before 1900. The
using the appropriate date.
The billing provider number
submitted on the claim is a
member of another Blue Cross
plan. The provider must resubmit
the claim to their local Blue Cross
plan via the BlueCard claim
process.
The billing provider number
submitted on the claim is a
member of another Blue Cross
plan. The provider must resubmit
the claim to their local Blue Cross
plan via the BlueCard claim
process.
Error Resolutions
F
TR-57
10/2007
Invalid Date
Invalid Date
Invalid Date
3241
3241
Invalid Date
3241
3241
Description
P0032f
P0032e
P0032d
P0032c
CPPS
Error
Code
A3
A3
A3
P0032d The similar illness/
symptom onset date___ is either
after the file creation date or
prior to 1900. Please correct and
resubmit.
P0032e The disability begin
date___ is either after the file
P0032f The admission date___ is
either after the file creation date or
resubmit.
Invalid Similar
Illness Date
Invalid Disability
Begin Date
Invalid Admission
Date
A3
122
122
122
122
A3
A3
A3
A3
510
510
510
510
STC01-1 STC01-2 STC10-1 STC10-2
Secondary Status
U277 Elements
D
U277 Details
Primary Status
U277 Elements
Invalid Onset of
Current Illness Date
• U277 - STC12
C
P0032c The initial onset of current
illness/symptom date___ is either
after the file creation date or
resubmit.
General
Description
B
A
Error
Code
New Pre-processor
Rejections
2300.DTP03 when DTP01
= 435
= 360 (repeats 5 times)
= 431
837P Loop/Data
Element
E
Error Resolutions
F
TR-58
10/2007
Invalid Date
Invalid Date
Invalid Date
3241
3241
3241
Description
P0032i
P0032h
P0032g
CPPS
Error
Code
A3
A3
A3
P0032h The other insured date
of birth___ is either after the file
P0032i The date of service___ on
service line ___ is either after the
file creation date or prior to 1900.
Invalid Other
Insured Date of
Birth
Invalid Service Line
Date
122
122
122
A3
A3
A3
510
510
510
STC01-1 STC01-2 STC10-1 STC10-2
Secondary Status
U277 Elements
D
U277 Details
Primary Status
U277 Elements
Invalid Discharge
Date
• U277 - STC12
C
P0032g The discharge date___ is
either after the file creation date or
resubmit.
General
Description
B
A
Error
Code
New Pre-processor
Rejections
= 472
2320.DMG02 (repeats up
to 10 times)
= 096
837P Loop/Data
Element
E
Error Resolutions
F
TR-59
10/2007
P0032j
P0033a
P0033b
Invalid Date
Rendering and Billing Prov
#’s must be the same
Place of Service not valid for
Billing Provider
P11{DC}
P10{DC}
3241
Description
CPPS
Error
Code
A3
A3
P0033a Billing and individual
provider IDs must be the same on
ancillary claims. Please correct
and resubmit.
P0033b The place of service
___ you submitted is invalid for an
ancillary claim. Please correct and
resubmit.
Billing and
Individual provider
ID must be the
same on Ancillary
claims
Invalid Place of
Service for Ancillary
claim
A3
122
122
122
A3
A3
A3
249
153
510
STC01-1 STC01-2 STC10-1 STC10-2
Secondary Status
U277 Elements
D
U277 Details
Primary Status
U277 Elements
Invalid Disability
End Date
• U277 - STC12
C
P0032j The disability end date___
is either after the file creation date
or prior to 1900. Please correct
and resubmit.
General
Description
B
A
Error
Code
New Pre-processor
Rejections
2400.SV105 or 2300.
CLM05-1 and 2010AA.
REF or 2420A.REF when
REF01 = 1A or 1B
2010AA.REF or 2420A.
REF when REF01 = 1A
or 1B
837P Loop/Data
Element
E
12 - HI (Home Infusion)
12 - DM (Durable Medical Equip)
12 - NU (Private Duty Nursing)
41 - AU (Ambulance)
42 - AU (Ambulance)
Place of Service - Ancillary
Provider Type
The place of service on the
claim is not valid for the ancillary
provider type submitted on the
claim. The provider must submit
a valid place of service that
is applicable for the ancillary
provider.
The individual provider number
on the claim is not the same as
the billing provider number. The
with the appropriate individual
provider number.
Error Resolutions
F
TR-60
10/2007
3106
3105
3104
Missing Other Payers Liability
Data (2320, AMT02 Payer
Amount Paid)
_Missing Other Payers Liability
Data (2320 or 2430 CAS03)
Data (2320 or 2430 CAS02)
Data (2320 or 2430 CAS01),
NDC code not present
P13{DC}
3103
Procedure not valid for Billing
Provider
P14{DC}
Description
P0034b
P0034a
P0033d
P0033c
CPPS
Error
Code
Missing OPL paid
amount
P0034b When SBR09 is “S”
(Secondary) or “T” (Tertiary),
the other payer liability amount
is required. Please correct and
resubmit.
P0034a When SBR09 is “S”
(Secondary) or “T” (Tertiary), the
other payer liability adjustment
information is required. Please
A3
A3
A3
P0033d The NDC code is required
for Home Infusion claim. Please
NDC code required
for Ancillary claim
Missing OPL
adjustment
information
A3
122
122
122
122
A3
A3
A3
A3
171
171
218
507
STC01-1 STC01-2 STC10-1 STC10-2
Secondary Status
U277 Elements
D
U277 Details
Primary Status
U277 Elements
P0033c The procedure code ___
on service line ___ is not valid for
billing provider. Please correct and
resubmit.
• U277 - STC12
C
Procedure code
not valid for
Billing Provider on
Ancillary claim
General
Description
B
A
Error
Code
New Pre-processor
Rejections
2320.AMT02 when AMT01
=D
2320.CAS or 2430.CAS
2410.LIN03
2400.SV101-2 and
2010AA.REF or 2420A.
REF when REF01 = 1A
or 1B
837P Loop/Data
Element
E
The “Payer Amount Paid”
information is required when
SBR01 is “S” (Secondary) or
“T” (Tertiary). These indicators
denote that another payer paid
the claim. The provider must
appropriate data.
The claim was submitted without
the required data elements that
are needed to adjudicate an
Other Party Liability (OPL) claim.
claim with the appropriate data.
The claim was submitted without
the NDC code for a home
infusion provider. If the procedure
code begins with a “B” and if
procedure codes J7190 - J7195
or J7198 - J7199 are submitted
on the claim, the NDC code is
required.
The procedure code on the claim
is not valid for the billing provider
type submitted on the claim.
The provider must submit a valid
procedure code that is applicable
for the ancillary provider.
Error Resolutions
F
TR-61
10/2007
3112
3111
3110
3109
3108
3107
3117
_Missing Other Payers
Liability Data (2320A,
NM109)
NM108)
NM104)
NM103)
NM102)
NM101)
Missing Other Payers Liability
Data (2320, AMT02 Patient
Responsibility Amount)
Description
P0034d
P0034c
CPPS
Error
Code
Missing OPL
entity name or
organization
information
Missing OPL patient
responsibility
amount
General
Description
B
A
Error
Code
New Pre-processor
Rejections
P0034d When SBR09 is “S”
(Secondary) or “T” (Tertiary), the
other payer name is required.
P0034c When SBR09 is “S”
(Secondary) or “T” (Tertiary),
the other payer liability patient
responsibility amount is required.
• U277 - STC12
C
Secondary Status
U277 Elements
A3
A3
122
122
A3
A3
171
171
STC01-1 STC01-2 STC10-1 STC10-2
Primary Status
U277 Elements
D
U277 Details
2320.NM1
2320.AMT02 when AMT01
= F2
837P Loop/Data
Element
E
The “Other Payers Information”
is required when SBR01 is “S”
(Secondary) or “T” (Tertiary).
These indicators denote that
another payer paid the claim. The
with the appropriate data.
The “Patient Responsibility
Amount” is required when
SBR01 is “S” (Secondary) or
“T” (Tertiary). These indicators
denote that another payer paid
the claim. The provider must
appropriate data.
Error Resolutions
F
TR-62
10/2007
N/A
N/A
N/A
N/A
N/A
N/A
Description
P0035c
P0035b
P0035a
CPPS
Error
Code
A3
A3
A3
P00035b The Rendering Provider
NPI ______ you submitted failed
check digit validation. Please
P00035c The Service Facility NPI
_____ you submitted failed check
digit validation. Please correct and
resubmit.
Invalid NPI Check
Digit Validation
Invalid NPI Check
Digit Validation
122
122
122
A3
A3
A3
562
562
562
STC01-1 STC01-2 STC10-1 STC10-2
Secondary Status
U277 Elements
D
U277 Details
Primary Status
U277 Elements
P00035a The Billing Provider NPI
______ you submitted failed check
digit validation. Please correct and
resubmit.
• U277 - STC12
C
Invalid NPI Check
Digit Validation
General
Description
B
A
Error
Code
New Pre-processor
Rejections
2010AA.NM109 when
2010AA.NM108 equal XX
2010AA.NM109 when
2010AA.NM109 when
837P Loop/Data
Element
E
The service facility NPI submitted
on the claim is invalid. The
using a valid service facility NPI.
The rendering provider NPI
submitted on the claim is invalid.
claim using a valid rendering
provider NPI.
submitted on the claim is invalid.
claim using a valid billing provider
NPI.
Error Resolutions
F
TR-63
Billing — Transactions — Addendum B
Addendum B
CMS-1500 (08/05) Claim Form
10/2007
TR-64
Billing — Transactions — Addendum B
CMS-1500 (08/05)
ABC1234567800
Doe, John B.
03 20
Doe, John B.
71
1234 Main Street
1234 Main Street
Philadelphia
Philadelphia
PA
19111
610 555-5555
15974
72431
21
PA
19111
610 555-5555
Doe, Mary
10
Member I.D. Number
(No Suffix for CompSelect®/
Comprehensive Major
Medical [CMM])
03 20
71
Watch Repair, Inc.
70
self-employed
Personal Choice
HMO, Inc.
Referring Provider’s
Current Provider ID
two-character qualifier ID
10 28
06
1B 0123456789
999999999
Josephine Smith, M.D.
ZZ207LP2900X
ZZ qualifier ID and Billing Provider’s
Primary Taxonomy Code
11
01
06
11 04
06
Referring Provider’s NPI
401
251
8
123456789
11 02 06
11
02 06 21
11 03 06
11 03
06 21
6
99205
6
20600
25
Referral/Preauthorization Number
1
$50 00
1
2
$250 00
1
1B
1234567000
8888888888
Two-character qualifier ID
of the Rendering Provider
Modifier (if applicable)
Provider’s
Federal
Tax ID #
(Billing Entity)
Service
Facility
NPI
22-1234567
��
11/5/06
Service Facility
two-character
qualifier and
Current Provider
ID number
ABC Hospital
123 Street
Anytown, PA 19003
0000001234
$100
Billing
Provider
NPI
1B1234567002
Green items are required by Independence Blue Cross and its affiliates for payment.
Blue items are required for payment when applicable to the patient’s condition/situation.
Black items are optional.
10/2007
00
215 555-5555
Billing Provider
ABC Medical Group
two-character
qualifier ID and
8 North American Street
current provider
Anytown, PA 19003
identification number
2222222222
1B1234567001
Indicates new field and/or requirement.
Indicates field required for processing.
TR-65
Billing — Transactions — Addendum C
Addendum C
CMS-1500 (08/05)
Key Fields
10/2007
TR-66
CMS 1500 (08/05)
Billing — Transactions — Addendum C
ABC1234567800
Doe, John B.
03 20
Doe, John B.
71
1234 Main Street
1234 Main Street
Key
Fields Must be Entered
Correctly on CMS-1500
(08/05) to Avoid Claim
Philadelphia
PA
Philadelphia
PA
Returns or Rejections
19111
Doe, Mary
19
21
610 555-5555
15974
17b
17a
72431
10
19111
610 555-5555
03 20
71
24J
Watch Repair, Inc.
24I
shaded
Personal Choice
shaded
70
self-employed
24J
unshaded
HMO, Inc.
Current Provider ID
two-character qualifier ID
10 28
06
1B 0123456789
999999999
Josephine Smith, M.D.
ZZ207LP2900X
ZZ qualifier ID and Billing Provider’s
Primary Taxonomy Code
11
01
06
11 04
06
Referring Provider’s NPI
401
251
8
123456789
11 02 06
11
02 06 21
11 03 06
11 03
06 21
6
99205
6
20600
Service
Facility
NPI
22-1234567
��
11/5/06
25
Service Facility
two-character
qualifier and
Current Provider
ID number
ABC Hospital
123 Street
Anytown, PA 19003
0000001234
10/2007
32b
$50 00
1
2
$250 00
1
$100
Billing
Provider
NPI
1B1234567002
Green items are required by Independence Blue Cross and its affiliates for payment.
Blue items are required for payment when applicable to the patient’s condition/situation.
Black items are optional.
32a
1
1B
1234567000
8888888888
Two-character qualifier ID
of the Rendering Provider
00
215 555-5555
Billing Provider
ABC Medical Group
two-character
qualifier ID and
8 North American Street
current provider
Anytown, PA 19003
identification number
2222222222
1B1234567001
Indicates new field and/or requirement.
33a
33b
TR-67

Your Quick Reference to Billing, Referrals, and e

Transcription

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