Claim Submission and Payments

When submitting claims, transfer the member’s identification (ID) number exactly as printed on the ID card. Remember to include the leading three-character prefix and enter it in the appropriate field on the claim form.

When completing the CMS-1500 form, note the following:

• Box 25– Enter the applicable tax ID number.
• Box 31– Enter the physician or provider’s name that performed the service.
• Box 33– Enter the “contract name” of physician or provider who performed the service.

HIPAA's Administration Simplification provision requires a standard unique identifier for each covered healthcare provider (those that transmit healthcare information in an electronic form in connection with HIPAA-standard claim transactions). The NPI replaces all proprietary (payer-issued) provider identifiers, including Medicare ID numbers (UPINs). It doesn't replace your tax ID number (TIN) or Drug Enforcement Administration (DEA) number. TINs are still a required element for claims. Electronic claims without a TIN are rejected as incomplete. If you need more information about the NPI mandate, Medicare timelines, and/or the enumeration process, visit the CMS website.

You can submit claims daily, weekly, or monthly. The earlier you submit claims, the earlier we process them. Ideally, we'd like you to submit claims within 60 calendar days of the covered services, but no later than 365 calendar days. For most plans, we'll deny claims received more than 12 months after the date of service with no member responsibility. Refer to your contract for further claims submission information.

If you are unable to submit claims electronically, you can submit paper claims on CMS-1500 or UB-04 forms. To speed claims processing, we use document imaging and optical character recognition (OCR) equipment to read your claims. To ensure that OCR reads your paper claims accurately:

• Use only red CMS-1500 forms (no photocopied forms).
• Type forms in black ink (handwritten forms cannot be read by OCR equipment).
• Don’t fold, staple, or tape your claim.
• Be sure information lines up correctly within the respective fields (data that overlaps another field/box cannot be read accurately).
• Don’t write or stamp extra information on the form.
• Avoid white correction fluid.
• Avoid highlighting information.

Submitting a corrected claim may be necessary when the original claim was submitted with incomplete information (e.g., procedure code, date of service, diagnosis code). The preferred process for submitting corrected claims is to use the 837 transaction (for both professional and facility claims) using claim frequency code 7.

If submitting a corrected claim on paper, remember to:

• Submit as a replacement claim, clearly marking the claim as a corrected claim; failure to indicate that a claim is a corrected claim may result in a denial as a duplicate claim.
• Bill all original lines-not including all of the original lines will cause the claim to be rejected.
• Attach a completed “Corrected Claim - Standard Cover Sheet.”

Obtain Corrected Claim - Standard Cover Sheets at onehealthport.com in the administration simplification claims processing section, or under Forms on our provider website.

You can obtain the status of a claim:

1. Online: The best method to check the status of a claim is to visit our website. Information is available 24 hours a day, seven days a week.
2. Customer Service: If you don't have Internet access, contact Customer Service by calling 800-722-4714, option 4, or by calling the phone number on back of member's ID card.
3. Interactive Voice Response (IVR): Available 24 hours a day, seven days a week. IVR provides claims information.

A fragmented or split professional billing is defined as professional services rendered by the same provider for the same date of service and submitted on multiple professional claim forms.

• We require all professional services rendered by the same provider for the same date of service, to be submitted on one claim form.
• An exception to this rule is when a Medicare patient receives services that Medicare specifically requires to be submitted on separate claim forms.

Be sure to submit a paper CMS-1500 claim form or electronic 837P claim form that is complete and accurately filled out. Here are common reasons why claims suspend or reject:

• Information doesn't match: Physician/provider information doesn't exactly match what is in our payment system.
• Rebilling: Records are missing when rebilling with a different diagnosis or other change. The claim rejects if records are not attached that support the change.
• Anesthesia: The hours/minutes for anesthesia claims are not included. Anesthesia time is billed in units to represent minutes and additional base units for the code.
• Home IV drugs: NDC number and quantity is missing.
• Advanced registered nurse practitioner: Supervising physician's name is missing for non-credentialed and/or not contracted ARNP.
• PAs: Supervising physician's name is missing for PA (Note: A PA does not need to bill with a supervising physician if he/she is a Surgical Assistant and has completed the paperwork to be set up independently in our payment systems).
• Codes: The person submitting the claim used invalid CPT/HCPCS, modifiers, or diagnosis codes.
• The onset date was missing from box 14 in the CMS-1500 claim form.
• Incorrect member number: Provider billing used the member's social security number (SSN) instead of the non-SSN member identification number on the member's card.

Contact Customer Service with questions regarding claims processing, or send a copy of the voucher highlighting the claim in question and the inquiry reason. If we processed the original claim incorrectly, you do not need to rebill. The claim will be reprocessed and reflected on the payment voucher. You can reach Customer Service by calling 877-342-5258, option 2, or by calling the Customer Service phone number on the back of the member's ID card. Before discussing member claim information, the Customer Service representative must verify the identity of the caller.

Our electronic claims process electronically separates and routes only valid claims for processing. Invalid claims are reported back to the provider with rejection details. There is no charge to healthcare providers who submit electronic claims directly to us.

If you submit your claims electronically, you may receive electronic remittance for the following:

• Premera Blue Cross Blue Shield of Alaska Participating (Traditional/Indemnity) and Preferred/BestCare (PPO)
• Premera Dental
• FEP
• National Account Service Company (NASCO)
• BlueCard (out of area)
• Dimensions (HeritagePlus, HeritageSelect, or Global)

Advantages

Submit claims electronically for:

• Faster claims payment turnaround
• Less time spent on claims preparation
• Validation to ensure that they are HIPAA-compliant
• Detailed claim acceptance and rejection reporting

Remittance is available online-just let us know. Your office staff can then post this remittance manually or electronically (if your software has electronic posting capability).

Getting started

To help you move from paper to electronic claims, follow these steps:

1. If you are interested in purchasing a new computer system, ask us for a list of vendors that submit claims to us in the HIPAA standard ANSI 837 format.
2. If you already have a computer system, notify your software vendor of your desire to convert to electronic claims. You will need special software to send insurance claims electronically.
3. Call EDI at 800-435-2715 for information. They will send you the following documents:
   • EDI Enrollment Information
   • Secure Transport (ST) User Guide
   • Testing process information
4. Your software vendor can help you set up your computer to accommodate Premera's billing requirements.
5. Plan to submit test claims. Continue to submit paper claims until you are told to stop. We review test claims for accuracy, but we don't process them for payment.
6. An EDI representative will review the test claims with you or your vendor. We'll notify you in writing or by telephone when you have successfully completed the test phase. When this notification has occurred, change the indicator on your claims from (T)est to (P)roduction and begin submitting live electronic claims. At that time, please discontinue submitting paper claims.

Submitting secondary claims electronically

Electronic claims can be sent when we are the secondary insurance payer. If you bill your claims using the ANSI 837 electronic format, then you must include the Coordination of Benefits (COB) information from the primary coverage payer in your claim. COB information is allowed when the primary coverage is with a commercial payer; this generally excludes Medicare and FEP. If you are unsure how to submit secondary claims electronically, contact your practice management system vendor or contact an EDI representative at 800-435-2715.

Coordination of Benefits (COB) is a provision included in both member and physician and provider contracts. When two or more health plans cover a member, COB protects against double or over-payment. When we process a claim, we coordinate benefits if the member has other primary coverage from another carrier, our health plan, service plan, or government third-party payer. We'll coordinate the benefits of the members plan with those of other plans to make certain that the total payments from all plans aren't more than the total allowable expenses.

We abide by the following COB standards to determine which insurance plan pays first (primary carrier) and which pays second (secondary carrier). Briefly, these rules are as follows:

1. A member is primary on the plan in which he/she is the subscriber versus the plan in which he/she is a dependent. When a member is the subscriber on more than one plan, when both plans have a COB provision, the plan with the earliest start date pays first (primary).
2. When a dependent is double-covered under married parents' health plans, the primary plan is the coverage of the parent with his/her birthday earlier in the year, regardless of their actual age. This standard is called the “Birthday Rule.”
3. When dependent children are double-covered by divorced parents, coverage depends on any court decrees. Generally, if the court decrees financial responsibility for the child's healthcare to one parent, that parent's health plan always pays first. If there are no court decrees, the plan of the parent with custody is primary.

Some group contracts are not subject to state regulations may have unique COB rules that could change the order of liability.

Billing information

Primary submission: Show all insurance information on the claim, and then submit the claim to the primary plan first.

Secondary submission: When submitting secondary claims to us, submit the primary processing information with the submission of the secondary claim.

How payments are made

When applicable, we will suspend payment until we determine which carrier is primary and which is secondary. We may send a questionnaire to the member regarding possible duplicate coverage. We need the member to promptly complete and return this questionnaire to process claims in a timely manner. When we are the primary carrier, we calculate and pay benefits routinely.

It is important to file a claim with all insurance companies to which the member subscribes. To ensure prompt and accurate payment when Premera is the secondary carrier, we encourage you to send the secondary claims with the primary processing information as soon as you receive it.

If we do not receive the EOB, and are unable to obtain the primary payment information by phone, the claim will be denied with a request for a copy of the primary EOB before processing can be completed. If you have questions about COB, contact Customer Service by calling the phone number on the back of the member's ID card.

Subrogation permits the plan to recover payments when the negligence or wrongdoing of another causes a member personal illness or injury. A subrogation provision is included in both member and physician/provider contracts. In third-party cases, this provision permits the plan to recover the medical bill costs on behalf of the member.

Injury Accident Claims

The member's benefit program contains special provisions for benefits when an injury or condition is:

• Caused by another party (e.g., slip and fall, medical malpractice, etc.)
• Covered under the provisions of motor vehicle medical policy, personal injury protection (PIP), medical payments (Medpay)
• Uninsured (UIM) and/or underinsured (UM) motorist or other similar coverage (e.g., homeowners, commercial medical premises)
• Covered by Worker's Compensation.

An onset date should be recorded on all accident-related claims. The claim(s) will suspend and a processor will review to determine whether to send an Incident Questionnaire (IQ) to the member. (The IQ is available in the Provider Library under Forms. You can print and assist the member in completing the form, but it's important to review the instructions included with the form because the patient must complete the form and then sign it.) If the member does not return the IQ within the specified timeframe, we'll l deny all related claim(s). Once the IQ is returned, all claims are reviewed and processed based on the information supplied. The member or provider can submit the completed IQ using one of the following methods:

• Fax it to: 425-918-5878
• Mail it to: Subrogation Department
  MS 227
  P.O. Box 327
  Seattle, WA 98111-327

The member may contact Customer Service (the number is on the back of the ID card) to update IQ information over the phone. If all pertinent information is obtained, the claim(s) will then be processed according to the member's contract benefits. If we need additional information for subrogation determine to pay or deny, the IQ will either be sent back to the member requesting the information, or subrogation will make two calls within five days of receiving the IQ. If member does not return the call, claims will be denied until information is received. If member returns the call and the information is obtained, claims will be processed.

We will send the member an IQ if the claim(s) is potentially accident-related. When the member completes and returns the IQ form to Calypso Subrogation department, a representative will screen the document to determine if another party is responsible for processing claims prior to the health carrier stepping in. This review is necessary to determine whether the claim(s) should be covered by a first-party carrier (e.g., PIP, Med Pay or similar coverage - homeowners or a commercial medical premise policy).

Benefits are not available through us until the first-party carrier has exhausted, denied, or stopped paying due to its policy limits. Once we have received a payment ledger from the first-party carrier(s) showing where they paid out their limits (with dates of services, provider names, total charges, total paid, etc.), claims will be processed accordingly and under the terms of our subscriber's contract. If the IQ states that there is no first-party coverage(s) available, but there is a third-party that is responsible for the incident, we will process all related claims based on the member's contract with us until all parties are ready to negotiate a settlement for possible reimbursement.

Workers' compensation

Workers' Compensation will pay when the member's employer is liable to pay medical bills resulting from illness or injury arising out of, or in, the scope of employment. All of our contracts exclude coverage for care covered under the Workers' Compensation Act.

Claims submitted that indicate possible Workers' Compensation illness or injuries are investigated. We send the member a questionnaire requesting information to determine if benefits are available. If we do not receive a response within the specified period, the claim(s) is denied pending further information. If the information received indicates an on-the-job illness or injury, both the member and physician/provider will receive a denial that states the Premera contract excludes work-related conditions. If Workers' Compensation denies payment of such claims, Premera will pay according to the subscriber's contract benefits after receiving a copy of a valid denial.

In some contracts, we use a RBRVS methodology, developed by CMS, to calculate its fee-for-service fee schedule. RBRVS is a method of reimbursement that determines allowable fee amounts based on established unit values as set norms for various medical and surgical procedures, and further based on weights assigned to each procedure code. These weights are then multiplied by the dollar conversion factor we publish. The conversion factor represents the dollar value of each relative value unit (RVU). When the conversion factor is multiplied by the total RVUs, it will yield the reimbursement rate for the specific service (or code).

There are three separate components that affect the value of each medical service or procedure:

• Physician work - the work value reflects the cost of the physician's time and skill for each service.
• Practice expense - the physician's direct (non-physician labor, medical equipment, medical supplies) and indirect (general office supplies, rent, utilities, office overhead) costs related to each service.
• Malpractice insurance - the malpractice insurance component

RVUs are assigned to each of these components. CMS also uses RVUs to allocate dollar values to each CPT or HCPCS code. For more information about RBRVS methodology visit the CMS website at cms.gov/physicianfeesched.

For services not listed in the RBRVS published annually in the Federal Register, we use Optum's Essential RBRVS (previously known as Ingenix Essential RBRVS and St. Anthony's Complete RBRVS).

We use an automated processing system to adjudicate claims. When processing claims, the system:

• Checks for eligibility of the member listed on the claim
• Checks for completeness of the claim
• Confirms the accuracy of the information
• Compares the services provided on the claim to the benefits in the subscriber’s contract
• Applies industry standard claim edits and applicable payment policy criteria
• Concludes the payment amount

Actual payment is subject to our fee schedule and payment policies; to a member’s eligibility, coverage, and benefit limits at the time of service; and to claims adjudication edits common to the industry.

We regularly update (at least quarterly) our claims editors to keep pace with changes in medical technology, as well as CPT codes, HCPCS codes, and ICD-10-CM/PCS Diagnosis and Procedure code changes, standards, and complexities. These claim editors evaluate billing information and coding accuracy on submitted claims and assists in achieving consistent, accurate, and timely processing of physician and provider payments.

We follow industry standard coding recommendations and guidelines from sources such as the CMS, CPT, and AMA, and other professional organizations and medical societies and colleges. National Correct Coding Initiative (NCCI) editing is followed when applicable. Any exceptions are documented as Payment Policies. It is only after we determine a member’s eligibility or coverage that payment policies and edits are applied. Payment policy:

• Applies to professional claims, including some facility claims
• Does not determine the reimbursement dollar amount for any particular service (reimbursement is specific to the provider's applicable fee schedule).
• Is distinct from our medical policy, which sets forth whether a procedure is medically necessary/appropriate, investigational or experimental and whether treatment is appropriate for the condition treated.

You can find our payment policies on our website in the Library, under Reference Info. Always refer to the online branded versions of our payment policies to ensure to most current and accurate information.

Calypso, our affiliate, processes refunds and overpayment requests. When Calypso identifies an overpayment, they mail an Overpayment Notification letter with a request for the overpaid amount.

Sometimes an office returns a check to us that represents multiple claims because a portion (see Threshold below) of the payment may be incorrect. In these cases, please don't return the check to us. Instead, deposit the check, circle the claim in question on the Explanation of Payment (EOP) and include a short explanation as to why there was an overpayment. After these steps are completed, you can choose one of the following options to resolve the overpayment:

• Mail the overpayment amount to our finance department (address on check) along with a completed Refund Request form, or
• Mail a completed Overpayment Notification form (found in our online library under Forms) and mark the box requesting a voucher deduction to recover the overpayment on future claim payments.

Calypso will apply the refund to the claim as soon as they receive the refund. If you require a written refund request before mailing the overpayment, contact Calypso directly at 800-364-2991. We do not request refunds for overpayments less than $25, but you may submit these voluntarily. (BlueCard will request refunds regardless of the dollar amount.) Refund total overpayment amounts within 60 days of initial notice to avoid having outstanding refund amounts offset against future payments.

We process your claims as soon as we receive them. We also apply the following prompt pay standards set by Washington's Office of the Insurance Commission to our claims adjudication process in order to:

• Pay or deny 95 percent of a provider's monthly clean claims within 30 days of receipt; and
• Pay or deny 95 percent of a provider's monthly volume of all claims within 60 days of receipt.

If the standards are met, the regulation does not require interest for those individual claims paid outside of the 95 percent threshold.

Clean claim definition

A clean claim is one that has no defect or impropriety, including any lack of any required substantiating documentation, or particular circumstances requiring special treatment that prevents timely payments from being made on the claim. This includes any missing required substantiating documentation or particular circumstances requiring special treatment.

Clean Claim Exclusions

Claims may also be delayed during processing if:

• They are suspended due to the group or individual's non-payment of premium or dues.
• They have Coordination of Benefits when we are the secondary carrier on the claim.
• They require completion and mailing of an Incident Questionnaire for possible accident investigation or a Workers Compensation injury (claims in subrogation).
• They include a request of medical records for review.

Applying interest

If we fail to satisfy any of the above standards, commencing on the 31st day, we’ll pay interest at a 15 percent annual rate on the unpaid or un-denied clean claim. Interest will not be calculated on unclean claims regardless of how long it takes to process them.

Interest vouchers

Prompt Pay interest is currently calculated monthly for the previous month's paid claims. Payments are issued under a separate voucher and mailed to the address on the original claim. Included with the interest voucher is a summary report detailing the claims for which interest payments have been applied during that period.

Interest threshold

There is a minimum threshold of $25 for monthly interest payments on delayed clean claims. An interest check is issued only for months in which the accumulated interest is equal to or greater than the minimum threshold of $25. Interest less than $25 will continue to accrue until it reaches that threshold or until December of each year. To help your office complete year-end accounting, each December we'll issue you a check for the accrued interest we owe you, even if the amount is below the threshold.

Prompt pay unit

Contact the Prompt Pay Unit at 800-932-2883 for inquiries regarding the following:

• Voucher-related interest payments
• Application of interest payments
• Amount of interest paid
• Lack of interest payment

If your organization is contracted with Premera, most practitioners must be credentialed, with the exception of hospital-based practitioners. Learn more about which practitioners need to be credentialed by viewing our credentialing matrix, located in our credentialing manual, available by request from Credentialing.Updates@premera.com.

Practitioners who aren’t credentialed may have their claims returned until they submit a complete credentialing application. Lack of credentialing can be grounds for termination from Premera’s network.

You can learn more about credentialing by visiting the provider section of our website