Where can I find a copy of BlueChoice HealthPlan's bundling guidelines? From the Medical Policies and Clinical Guidelines page on our website you can review CAM 138 Corporate Administrative/Medical Policy Guidelines (Medical Necessity, Investigational/Experimental) for our bundling guidelines. You can also get this information from the member’s specific benefit plan. It is important to note that a claim has to be processed before it can be determined which codes will bundle.
Will BlueChoice® accept the new X modifiers? Yes, BlueChoice accepts the new modifiers — XE, XP, XS and XU – the Centers for Medicare and Medicaid Services (CMS) mandated for use beginning Jan. 1, 2015. CMS established four new Healthcare Common Procedure Coding System (HCPCS) modifiers to define subsets of the -59 modifier, used to define a “Distinct Procedural Service".
Is 24/7 provider access required for all lines of business? Only BlueChoice primary care providers are contractually required to have physician accessibility 24 hours a day, seven days a week.
Can I submit the referring provider national provider identifier (NPI) if I do not have the rendering provider’s NPI? No. A provider advocate will contact providers that submit claims without the rendering information. The lack of rendering provider information will cause claim denials.
How can I receive your monthly provider newsletter? You can visit the Provider News page on our website to read the latest edition of BlueNewsSM for Providers and other publications. To have the newsletter sent to you via direct mail or email please contact Provider Education by emailing firstname.lastname@example.org.
Are there specific guidelines for pre-admission testing (i.e., EKG) when performed in physician’s office? If you perform pre-admission testing, such as an EKG in the physician’s office, then you should file it like any other procedure through an office visit. If the place of service is at the office, then you bill as an office claim. When you do the pre-admission testing at the hospital within 72 hours of admission, then you should bill it on the UB with the occurrence code 41.
Will you deny claims for “medical records not received in a timely manner” if you receive records after 10 calendar days? You should submit medical records immediately once you receive the request. If not, this will prolong any possible payment. The request may include a date range to return the medical records. Typically, we respond to medical records requests within seven to 14 days but no more than 30 days.
Why are copays doubled when our physician assistant sees a patient? We determine the copayment amount by the rendering physician specialty code and the member’s specific benefit plan.
How do I identify a BlueChoice member? Ask your patient for his or her current member ID card at each visit. Photocopy the front and back of the card regularly. Having the current card will enable you to submit claims with the appropriate member information (including prefix) and avoid unnecessary claim payment delays.
What should I collect from a BlueChoice member? Ask your patient for his or her current member ID card at each visit. Photocopy the front and back of the card regularly. Having the current card will enable you to submit claims with the appropriate member information (including prefix) and avoid unnecessary claim payment delays.
How do I file Medicare Crossover claims? File the claim to your Medicare carrier for primary payment. BlueChoice will not receive claim information for the member’s supplement plan (the secondary payer) until after Medicare has processed the claim and released it from the Medicare payment hold. GHI (the CMS vendor) normally will electronically forward Medicare secondary claims directly to the member’s supplement plan. Check the Medicare Remittance Notice to make sure GHI forwarded the claim. If it did, you do not need to take further action. The paper remittance notice will state "Claim information forwarded to: [Name of secondary payer]." The 835 (electronic remittance) record can also carry the secondary forwarding information. BlueChoice will send you your payment or processing information after it receives the Medicare payment. Please allow 45 days from the primary payment date for the processing of the secondary claim. If the claim did not cross over electronically to the supplement plan, you can file the secondary claim to BlueChoice electronically using My Insurance ManagerSM.
Should I resubmit a claim if I do not receive payment? No. If you have not received payment for a claim, do not resubmit the claim. We will deny it as a duplicate. This also causes member confusion because of multiple Explanations of Benefits (EOBs). You should always check claim status through My Insurance Manager. In some cases, a claim may pend because medical review or additional information is necessary. We will contact you when we need additional information in order to finalize the claim.
When should I contact my provider advocate? If you have a training request or question that is not related to specific claim disposition or member information, please contact your provider advocate.
Does BlueChoice require prior authorization? BlueChoice requests notification for any admission to a hospital or skilled nursing facility. This notification enables the member to access optional benefits, such as case management and disease management programs, along with discharge planning. Other services may also require prior authorization. You can get prior authorization using the Authorization/Precertification/Referral link in My Insurance Manager. You can submit prior authorization requests for BlueChoice. This feature also includes the referral and authorization status functions. Note: Prior authorizations do not guarantee payment of benefits. Claim payments are subject to the rules of the plan.