Excellus BlueCross BlueShield Participating … 2007 8—1 Excellus BlueCross BlueShield Participating Provider Manual 8.0 Billing and Remittance This section includes instructions

May 2007 8—i

Excellus BlueCross BlueShieldParticipating Provider Manual

8.0 Billing and Remittance

Table of Contents8.1 Electronic Submission of Claims Required.......................................................... 8—18.2 General Requirements for Claims Submission ................................................... 8—1

8.2.1 Timely and Accurate Filing ........................................................................ 8—28.2.2 Accurate and Complete ICD-9-CM Diagnosis Coding............................... 8—38.2.3 Using Modifiers ......................................................................................... 8—38.2.4 Additional References to Support Accurate Claims Submission ............... 8—3

8.3 How to Submit Electronic Claims ........................................................................ 8—48.3.1 Filing Tips.................................................................................................. 8—48.3.2 Response Reports .................................................................................... 8—48.3.3 Secondary Claims ..................................................................................... 8—58.3.4 Electronic Submittal of Medicare Part A Crossover Claims....................... 8—5

8.4 How to Submit Paper Claims .............................................................................. 8—58.4.1 Paper Claim Requirements ....................................................................... 8—68.4.2 Professional Services................................................................................ 8—68.4.3 New York State Clean Claim Submission Guidelines for CMS-1500 ........ 8—68.4.4 Hospital and Other Facility Services ......................................................... 8—78.4.5 Submitting Claims for Physician Extenders (NPs and PAs) ...................... 8—7

8.5 Claims Processing .............................................................................................. 8—88.5.1 Prompt Payment Law................................................................................ 8—88.5.2 Fee Schedules .......................................................................................... 8—88.5.3 Clinical Editing........................................................................................... 8—98.5.4 Clinical Editing Reviews .......................................................................... 8—108.5.5 Submission of Medical Records .............................................................. 8—108.5.6 Coordination of Benefits - Excellus BlueCross BlueShield as

Secondary Payor..................................................................................... 8—118.5.7 Inquiring about the Status of a Claim ...................................................... 8—13

8.6 Remittance........................................................................................................ 8—148.6.1 When Additional Information is Required ................................................ 8—148.6.2 Understanding the Remittance................................................................ 8—14

8.0 Billing and Remittance Excellus BCBS, Rochester Region

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8.6.3 Electronic Remittance Advice and Electronic Funds Transfer................. 8—148.7 Requesting a Change in Claims Payment......................................................... 8—15

8.7.1 Adjustments ............................................................................................ 8—158.7.2 Clinical Editing Review Requests............................................................ 8—168.7.3 Overpayments......................................................................................... 8—168.7.4 DRG Review Requests ........................................................................... 8—17

8.8 Charts, Forms and Samples ............................................................................. 8—17Chart: Tips for Accurate and Complete ICD-9-CM Diagnosis Coding............... 8—18Chart: CMS-1500 Field Descriptions ................................................................ 8—19Chart: UB-04 Field Descriptions........................................................................ 8—24Chart: Managed Care Remittance Field Descriptions................................... 8—28Sample: Managed Care Professional Remittance Advice................................ 8—30Chart: Indemnity Remittance Field Descriptions........................................... 8—31Sample: Professional Remit from Indemnity System ....................................... 8—33

May 2007 8—1

Excellus BlueCross BlueShieldParticipating Provider Manual

8.0 Billing and RemittanceThis section includes instructions for submitting claims to the Health Plan either electronically or onpaper. Unless instructed otherwise, participating providers should submit all BlueCross BlueShieldclaims, including BlueCard claims, to their local Excellus BlueCross BlueShield Health Plan.

8.1 Electronic Submission of Claims RequiredIn 1994, New York State enacted Public Health Law Section 2807-e(4) requiring hospitals, outpatientclinics, and physicians to submit health care claims to third-party payors electronically, using electronicformats designated by the New York State Department of Health. These formats have since beenreplaced by federally required formats (see below). However, the requirement to submit electronicallystill exists. Physicians who annually submit fewer than 1,200 claims to third party payors for directpayment were exempted from this requirement, but only upon obtaining a waiver from the Departmentof Health.The federal Health Insurance Portability and Accountability Act (HIPAA) also includes provisionsaffecting claims submission. While HIPAA does not require providers to submit claims electronically, itrequires all providers who submit claims electronically to do so using national HIPAA claims formatsand standards.All hospitals, outpatient clinics and physicians in New York who have not obtained a waiverfrom the Department of Health must submit claims to payors electronically, using HIPAAclaims formats and standards. In addition, any other provider who submits claims electronicallymust do so using HIPAA-compliant electronic formats. See paragraphs under heading How to SubmitElectronic Claims for more information about submitting claims electronically.

8.2 General Requirements for Claims Submissions Claims must be completed accurately and in full, in accordance with the instructions presented in

this manual. (See subsequent paragraphs.) The Health Plan cannot pay claims that are inaccurateor incomplete.


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Procedures must be identified by Current Procedural Terminology (CPT-4)1 or HCPCS codes.Diagnoses must be identified by ICD-9-CM2 diagnosis codes.

1The AMA is the owner of all copyright, trademark and other rights to CPT and its updates. AMAreserves all rights.2ICD-9-CM refers to the clinical modification (CM) of the most recent revision (9) of the InternationalClassification of Diseases, a book that lists diagnosis codes according to a system assigned by theWorld Health Organization of the United Nations. The ICD is distributed by the U.S. Printing Office inWashington, DC, and by commercial publishers.

Note: CPT, ICD-9, and HCPCS codes are revised at various times of the year by theorganizations responsible for them, the Centers for Medicare & Medicaid Services(CMS) and/or the American Medical Association (AMA). The Health Plan acceptsthese codes as implementation dates are designated by these organizations.

Place of service (POS) must be identified using the codes established by CMS. These codesapply to paper submittals of professional claims. Valid place of service codes for electronicsubmittals are included in providers’ implementation guides for HIPAA-compliant electronictransactions.

http://www.cms.hhs.gov/PlaceofServiceCodes/Downloads/placeofservice.pdf Procedures and diagnoses should be coded to the highest degree of specificity: for example,

include 4th and 5th digits on ICD-9-CM codes when applicable. Claims with referral or prior authorization requirements must include the authorization number. Facility billers must include a revenue code to identify services rendered. All required supporting material must be made available to the Health Plan upon request. When the national provider identifier (NPI) is fully implemented, claims submitted to all

payors, including Medicare, must include an NPI to identify each provider for which data isreported on the claim. The Health Plan cannot accept any claims that include legacy ID, with orwithout NPI, after May 22, 2008. With the exception of tax ID (required for IRS purposes), the onlyprovider ID allowed on claims after May 22, 2008 is the NPI.

When the national provider identifier (NPI) is fully implemented, facilities and multi-specialtyproviders with more than one taxonomy code must bill with the taxonomy code that most closelyrepresents the service provided. Failure to submit claims with the appropriate taxonomy code mayresult in incorrect payments.

8.2.1 Timely and Accurate FilingThe Health Plan requires that participating providers submit claims in a timely manner. Participating providers should submit all claims as soon as possible after rendering service (or

after the processed date of a primary payor’s explanation of benefits, or EOB). Most participatingprovider agreements contain a time limit within which claims will be accepted. Claims submittedafter that time limit may be denied for late filing. Providers should review their participating

Participating Provider Manual 8.0 Billing and Remittance

May 2007 8—3

provider agreements for these time limits. In the event of a declared pandemic, the Health Planmay extend the time limit to one year from date of service.

The Health Plan will reject claims with incorrect or incomplete entries in required fields outlined inlater paragraphs regarding submittal of electronic claims and paper claims. For example, theHealth Plan will reject all claims submitted without member ID numbers.

8.2.2 Accurate and Complete ICD-9-CM Diagnosis CodingSo that claims may process appropriately, it is important that submitters enter accurate and completeICD-9-CM diagnosis codes on all claims. The Health Plan encourages participating providers to followthe Tips for Accurate and Complete ICD-9-CM Diagnosis Coding included at the end of this section ofthe manual when coding any claim.

8.2.3 Using ModifiersThe Health Plan requires providers to use appropriate modifiers applicable to CPT codes and HCPCScodes when submitting claims. Using the right modifier may affect how the claim gets paid.There are certain instances where use of modifiers -25 or -59 is not appropriate. The Health Plan hasestablished guidelines for these circumstances. The guidelines are available on the Health Plan’s Website or from Provider Service.https://www.excellusbcbs.com/providers/administration/billing_resources/procedure_code_modifier_guidelines.shtmlComplete information about CPT codes and their modifiers is found in the most current issue of theAmerican Medical Association (AMA) manual on current procedural terminology (CPT). Completeinformation about HCPCS (Health Care Procedure Coding System) codes and their modifiers isavailable through the Web site http://www.cms.hhs.gov/MedHCPCSGenInfo/ or from variouspublications about the codes.

8.2.4 Additional References to Support Accurate Claims SubmissionIn addition to this manual, providers should refer to the following materials for information regardingclaims submission. Participating Provider Agreement. The Participating Provider Agreement describes the

provider’s rights and obligations with respect to claims submission to the Health Plan. This manualis intended to clarify provisions of the Agreement. In the event of a conflict between the provisionsof this manual and a Participating Provider Agreement, the Agreement supersedes this manual.

Current Procedural Terminology (CPT). CPT code books list descriptive terms and identifyingCPT codes for reporting medical services and procedures performed by providers. The HealthPlan requires the use of these codes on claims. CPT codes and all CPT materials are copyrightedby the American Medical Association.

International Classification of Diseases, 9th Revision, Clinical Modifications (ICD-9-CM).ICD-9-CM is a classification system that arranges diseases and injuries into groups according to


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established criteria. ICD-9-CM codes are required for reporting diagnoses and diseases to allCMS programs. The Health Plan also requires the use of these codes.

HCPCS Level II National Codes. HCPCS is the acronym for the HCFA (CMS) CommonProcedure Coding System. This system is a uniform method for health care providers and medicalsuppliers to report professional services, procedures, and supplies. The Health Plan requires useof HCPCS codes and associated modifiers for certain kinds of claims.

InterQual® Criteria. InterQual Criteria are guidelines for screening the appropriateness of medicalinterventions. The criteria are the property of McKesson Health Solutions LLC. McKesson ownsthe copyright. The Health Plan uses InterQual guidelines in evaluating inpatient appropriateness ofcare.

CMS Web Site. The CMS Web site is an extensive resource for forms, information and trainingmaterials associated with claims submission. The Web address is www.cms.hhs.gov/forms.

8.3 How to Submit Electronic ClaimsThe Health Plan accepts electronic claims through a clearinghouse. The clearinghouse accepts claimsdirectly, and also has the ability to accept and route electronic claims through emdeon™. Forinformation about how to submit electronic claims, including information about HIPAA claims formatsand standards, call Trading Partner Support at the number listed on the Contact List in Section 2 ofthis manual.

8.3.1 Filing Tips To support accurate and prompt claims processing, providers must use the correct Payor

Identification Number (Payor ID) when submitting claims electronically. All required fields must be populated. If any required field has no entry, the clearinghouse will

reject the claim. Use valid codes in fields such as those defining relationship, sex and place of service. If the code

entered does not match the type of service being billed, the claim may pend and require manualintervention to be processed.

8.3.2 Response ReportsFollowing submission of electronic claims, the provider will receive three reports: Clearinghouse Acknowledgment Report. This report indicates whether the transmission was

successful. Clearinghouse Response Report. This report validates claims and lists both accepted and

rejected claims.


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Payor Response Reports. Each type of claim—indemnity, managed care, etc.—will have its ownPayor Response Report. These reports will be available within 24 to 48 hours after submissionand will list only rejected claims.

Providers must review these reports, identify those claims that were rejected and correct theerrors and resubmit the claims.A provider should not consider that the clearinghouse has accepted an electronic claim until he/shehas received all three reports, and the Payor Response Report shows that the claim was not rejected.Providers are encouraged to keep copies of these reports to help verify claims submission.

8.3.3 Secondary ClaimsThe clearinghouse can accept secondary claims that are submitted electronically, includingthose where Medicare is primary. See the paragraphs Payment and Other Party Liability (OPL) underthe heading Coordination of Benefits for a list of what must be included in the claim in order for theHealth Plan to process a claim for which it is secondary payor.

Note: Not all vendors have the capability to submit secondary claims electronically.Before selecting or switching vendors, provider offices should contact Trading PartnerSupport to determine whether a specific vendor has this capability.

8.3.4 Electronic Submittal of Medicare Part A Crossover ClaimsProviders should not send claims to the Health Plan if the primary payor is Medicare. Medicareforwards balances to the Health Plan as secondary payor, after their payment. If the Explanation ofMedicare Benefits (EOMB) from Medicare indicates that the claim has been forwarded to the HealthPlan for processing, providers should suppress the secondary billing of these claims.Providers who do not receive payment from the Health Plan for a balance after a Medicare Part Aclaim should wait a minimum of 45 days from the Medicare payment date before submitting the claimto the Health Plan. This will help avoid duplicate claims. The Health Plan will not service MedicarePart A claims for secondary payment before the 45-day time period has elapsed.

8.4 How to Submit Paper ClaimsThere are two types of paper claim formats: CMS-1500 for most professional services UB-04 (CMS-1450) for hospital and other facility services

As stated earlier, all hospitals, outpatient clinics and physicians in New York who have not obtained awaiver must submit claims to payors electronically, using HIPAA claims formats and standards. (Seepreceding information about electronic claims submission.) In addition, many of the requirementsrelated to the national provider identifier apply to paper claims as well.Providers that submit on paper must do so according to the general requirements listed below underthe heading General Paper Claim Requirements.


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8.4.1 Paper Claim RequirementsThe Health Plan uses Optical Character Recognition (OCR) technology to read most paper claims.The following are important points to observe so that a paper claim can be processed using OCRrather than manually. Following these guidelines helps ensure timely processing. Use original forms that are printed in red. Do not use photocopies. Do not use red ink to fill in data field or attachment information. OCR equipment does not

recognize red ink. Entries should be typed and dark enough to be legible. Change the toner cartridge in your printer

regularly. So that information prints in the appropriate field, forms should be properly aligned prior to

printing. When submitting multi-page claims, submitters must ensure that identifying information for both

the provider and patient (Provider ID, Patient ID, patient account number, etc.) is reproduced andconsistent on all pages.

Use these guidelines when including attachments, such as medical records or primary payorinformation.

Submit paper claims to the claims address specified on the Contact List in Section 2 of thismanual.

For more information about accurate submission of paper claims, contact Provider Service.

8.4.2 Professional ServicesThe CMS-1500 form, entitled the Health Insurance Claim Form, was designed for use by non-institutional providers and suppliers.The Health Plan follows New York State Insurance Department claim submission guidelines indetermining what constitutes a complete, or “clean,” claim, unless stated otherwise in a provider’sparticipating provider agreement. See Clean Claim Guidelines below.

8.4.3 New York State Clean Claim Submission Guidelines for CMS-1500In addition to the NPI requirements, the New York State Insurance Department has claim submissionguidelines (Regulation No. 178, 11 NYCRR 230.1) that help interpret the prompt pay law. The HealthPlan follows these guidelines in determining what constitutes a complete, or “clean,” claim, unlessstated otherwise in a provider’s participating provider agreement. The guidelines specify that: A health insurer cannot reject a claim submitted on a CMS-1500 claim form as incomplete if the

claim contains accurate responses in specified fields, unless otherwise specified.


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In situations where one or more of the required fields is not appropriate to a specific claim, thesubmitter may leave the field blank.

Additionally, the guidelines state that the Health Plan may request additional information other thanthat on the claim form if the Health Plan needs this information to determine liability or make payment.In other words, depending on the service being billed, there may be other fields that the HealthPlan requires for processing. Further, the Health Plan is not prohibited from determining that a claimis not payable for other reasons.See the chart, CMS-1500 Field Descriptions, at the end of this section of the manual, for a descriptionof all fields on the CMS-1500.

8.4.4 Hospital and Other Facility ServicesCMS-1450, the UB-04 uniform billing form, is most commonly used by hospitals, skilled nursingfacilities, home health agencies and other selected providers to submit health care claims on paper.Providers that submit on paper using the UB-04 must do so according to the general requirementslisted above under the heading Paper Claim Requirements.The Health Plan’s requirements for the completion and submission of the UB-04 claim form are, for themost part, consistent with Medicare, Medicaid, and other major payors.To support accurate completion of UB-04 forms, providers should refer to the following: The contractual arrangements between the Health Plan and the provider as described in the

participating provider agreement. CMS requirements, as specified in the instructions for form CMS 1450 found on Web site

www.cms.hhs.gov/forms/ The chart, UB-04 Field Descriptions, at the end of this section of the manual.

8.4.5 Submitting Claims for Physician Extenders (NPs and PAs)The Health Plan follows Medicare guidelines for billing nurse practitioner or physician assistantservices performed incident to physician services. In such a case, the NP/PA’s incident to servicesmust be billed on a claim using only the collaborating/supervising physician’s Provider IDnumber. The claim will pay at 100 percent of the physician fee schedule. The NP/PA should notsubmit another claim for him/herself.When submitting a claim for services rendered in association with a collaborating/supervisingphysician but that are not incident to those of the collaborating/supervising physician, the submittershould complete one form for all services that the NP or PA provided in association with onecollaborating/supervising physician. In this case, the claim should include the PA or PA’s NPI asrendering provider.


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8.5 Claims Processing

8.5.1 Prompt Payment LawUnder New York State prompt payment law, applicable to claims received on or after January 22,1998, the Health Plan is required to decide, within 30 calendar days after receipt of a claim, whether topay, deny, or require additional information. The Health Plan requires providers to submit a “clean” claim (see above). If adjudication leads to the decision to pay the claim, the Health Plan will pay the claim within 45

calendar days after receipt. Providers should not resubmit before this 45-day period is up, unlessthe claim has been denied or returned unprocessed due to being incomplete.

If the Health Plan pays a claim more than 45 calendar days after receiving it, the Health Plan inmost cases will apply interest at the annual rate set by the Commissioner of Taxation or12 percent, whichever is greater. The Health Plan will make adjustments and/or pay interest whena claim was incorrectly paid due to Health Plan error, but only if the original claim was “clean.”

If adjudication leads to the decision to deny the claim, the Health Plan will notify the claimantwithin 30 calendar days of receipt of the claim and include an explanation of why the claim wasdenied.

If adjudication requires more information regarding the claim, the Health Plan will submit to theclaimant a detailed request for such information within 30 calendar days following receipt of theclaim.

8.5.2 Fee SchedulesThe Health Plan pays a participating provider for covered services provided to Health Plan memberson the basis of a fee schedule pursuant to the terms and conditions of the provider’s participationagreement. For more information about fee schedules, see Section 3 of this manual.The Health Plan deducts copayments, coinsurance, and permitted deductibles from the amount to bereimbursed, as applicable. These amounts are determined from the member’s benefit package, theproduct lines in which the provider participates, and the terms established in the provider’sparticipation agreement with the Health Plan.Fee schedules appropriate to a specific participating provider are available upon request from ProviderService. (For Health Plan addresses and telephone numbers, see the Contact List in Section 2 of thismanual.) In addition, physicians may access fee schedule information via the Health Plan Web site.

https://www.excellusbcbs.com/providers/administration/fee_schedules.shtml


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8.5.3 Clinical EditingAs part of the claims adjudication process, the Health Plan’s claims systems will review the claim todetermine that it fulfills Health Plan medical policies, referral requirements, preauthorizationrequirements (including those for medical necessity) and other benefit management specifications.The Health Plan uses clinical editing criteria based on code edits recommended by multiple sourcesfor the purpose of coding accuracy. The two principal sources are the American Medical Association’sCurrent Procedural Terminology (CPT) publications and the Centers for Medicare & Medicaid Servicesnational Correct Coding Initiative (CCI).The Health Plan may also use standards derived from evidence-based guidelines for medicine andclinical appropriateness that are developed by Health Plan medical staff and other medicalprofessionals. These medical policies outline the Health Plan’s determination of the appropriate use ofmedical services. Medical policies are available on the Provider pages of the Health Plan’s Web site,or upon request from Provider Service. (For Health Plan address and phone numbers, see the ContactList in Section 2 of this manual.)The Health Plan has incorporated clinical editing software into its claims systems. This software isused to determine the accuracy of procedural and diagnostic coding. The systems detect irregularitiessuch as: Unbundled procedures. Providers should not bill using several procedure codes when there is a

single inclusive procedure code that describes the same services. Incidental procedures. Providers should not bill separately certain procedures that are commonly

performed in conjunction with other procedures as a component of the overall service provided.An incidental procedure is one that is performed at the same time as a more complex primaryprocedure and is clinically integral to the successful outcome of the primary procedure.

Mutually exclusive procedures. Providers should not bill combinations of procedures that differin technique or approach but lead to the same outcome. In some instances, the combination ofprocedures may be anatomically impossible. Procedures that represent overlapping services oraccomplish the same result are considered mutually exclusive. Generally an open procedure anda closed procedure performed in the same anatomic site are not both recommended forreimbursement. Mutually exclusive edits are developed between procedures based on thefollowing CPT: limited/complete, partial/total, single/multiple, unilateral/bilateral, initial/subsequent,simple/complex, superficial/deep, with/without.

Patterns of utilization that deviate from generally accepted standards of clinical practice. Diagnoses/procedures inappropriate for gender, age, etc.


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To help avoid these errors, the Health Plan makes available some Web-based tools. One of the toolsis a vendor-based tool. When used, it can provide information to participating providers regarding themanner in which the Health Plan’s claim system adjudicates claims for specific CPT codes orcombinations of such codes without regard to a specific member’s benefits, provider fee schedule,employer agreements, or unique provider-specific contractual terms.https://www.excellusbcbs.com/providers/administration/billing_resources/terms_of_agreement_c3.shtmlIn addition to the above, the Health Plan has published on the Web site a list of each Health Plan-specific customization to the standard claims editing software currently in use. Providers who do notaccess the Internet at the office may obtain a copy of this list by calling Provider Service.https://www.excellusbcbs.com/providers/administration/billing_resources/clinical_editing_customization.shtmlCertain clinical edits will cause the system to generate a letter requesting additional information. Otherclinical edits may result in a denial, which will appear on the provider’s remittance advice. Providerscan also initiate a provider inquiry related to the edit determination by completing the Clinical EditingReview Request Form, described below.

8.5.4 Clinical Editing ReviewsProviders who disagree with a clinical editing determination for a procedure code combination mayrequest a clinical editing review. The Clinical Editing Review Request Form is available on the HealthPlan’s Web site or from Provider Service. Submit the form to the appropriate address listed on theform https://www.excellusbcbs.com/download/forms/clinical_editing_review_request_form.pdfIt is important to include any clinical documentation that will support the request. The Health Plan willmake a determination on the review and notify the provider in writing within 45 business days ofreceipt of all necessary information.Unless otherwise stated in the provider’s participation agreement, the Health Plan allows 120 daysfrom the date that the provider received the original claim determination to request a review. HealthPlan policy is to begin this 120-day time frame for review within five business days after the claimdetermination was sent to the provider.

8.5.5. Submission of Medical RecordsThe Health Plan may request submittal of relevant medical records to facilitate reviews for:

Services or procedures requiring preauthorization. Services or procedures where a Health Plan Medical Policy indicates criteria for medical

appropriateness or for services considered cosmetic, experimental or investigational. Quality of care and quality improvement. Medical necessity. Pre-existing conditions.


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Determination of appropriate level of care. Case management or care coordination

In addition, medical records may be needed for processing claims with: Modifier 22 (unusual procedural services) appended Modifier 62 (co-surgeon) appended

For services billed with unlisted, not otherwise specified, miscellaneous or unclassified codes, adescription of service is required. Additional records may be requested for these services, dependingon the description provided.In addition to the above, the Health Plan may request medical records relevant to:

Credentialing and Coordination of Benefits Claims subject to retrospective audit Investigation of fraud and abuse or potential inappropriate billing practices in circumstances

where there is a reasonable belief that such a need exists.There may be additional individual circumstances when the Health Plan needs to request medicalrecords to support claim processing.

8.5.6 Coordination of Benefits - Excellus BlueCross BlueShield asSecondary Payor

Health Plan subscriber contracts allow the Health Plan to coordinate payments with other payors,when a member is covered by more than one health benefit program. This is to prevent duplicatepayment for health care services. The member’s contract defines how the Health Plan implementscoordination of benefits (COB) for that contract.The Health Plan follows COB rules set forth by the New York State Insurance Department’sregulations, as well as COB guidelines established by the National Association of Health InsuranceCommissioners (NAIC). Medicare secondary payor rules take precedence.Participating providers agree to accept the Health Plan’s secondary payment for covered services andnot balance-bill the member/subscriber in excess of deductibles, copays and/or coinsurance.

Note: If a member has benefit coverage under two (or more) insurance plans thatboth require referrals, the member must have obtained a valid referral and/orauthorization from each plan to which a claim will be submitted.

The Health Plan follows the procedures below in order to prevent duplication of payment, preventoverpayment for services provided when a member has health benefits coverage under more than oneplan, and to clarify the order of primacy for Other Party Liability (OPL), Worker’s Compensation, NoFault and Medicare claims.


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General Adjudication PoliciesBrief summaries of special, statutory-based claims adjudication policies are provided below. They arefurnished only to provide information to providers in the context of this manual, and are not to be reliedupon as definitive legal statements of the coverage requirements relating to these programs.

Benefits will be coordinated as follows when members are covered under ExcellusBlueCross BlueShield and another health care benefit package.- When Excellus BlueCross BlueShield is primary, the Health Plan will reimburse the provider’s

billed charge or the fee schedule maximum (less any applicable copayment, coinsurance ordeductible), whichever is less.

- When Excellus BlueCross BlueShield is secondary, the Health Plan will reimburse theprovider for Health Plan covered services in conjunction with the primary plan, so that the twoplans pay no more than 100 percent of charges or the Health Plan fee schedule maximum(less any applicable copayment, coinsurance or deductible), whichever is less.

- If a member does not have a legal obligation to pay all or a portion of the provider’s billedcharges, then the Health Plan will have no obligation to pay any portion of the provider’s billedcharges.

- When Medicare is primary and denies the entire claim, and the claim is for covered services,the Health Plan will reprocess the claim as primary. All services provided will be subject tocopayments, preauthorization, and all other Health Plan policies regarding claims.

- When Excellus BlueCross BlueShield is secondary, the primary is not Medicare, there is abalance after the primary plan has made payment and Excellus BlueCross BlueShield or theother plan has reimbursed the fee schedule maximum for covered services, the provider maynot balance-bill the patient even if Excellus BlueCross BlueShield makes no payment.

As a secondary payor, Excellus BlueCross BlueShield will never pay more than it wouldhave if the Health Plan had been the primary health plan.

Workers’ Compensation and Other Employer Liability LawsHealth Plan health benefit programs exclude coverage for services obtained by a member as a resultof injury or illness that occurs on the job. These expenses are covered under the state’s Workers’Compensation Law.The Health Plan will closely review claims for injuries or illnesses, to determine if they are work-related. If necessary, the Health Plan will send the member a questionnaire. The Health Plan will denyany claim determined to be work-related, and will notify the provider that he/she must file the claimthrough the applicable Workers’ Compensation carrier or through the member’s employer.If the Health Plan mistakenly pays a claim on a work-related injury or illness, and later discovers thatthe injury or illness was work-related, the Health Plan will take steps to obtain appropriate recoveriesfrom all parties who have received claims payments.


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MedicareA Health Plan member continuing to work and remaining actively employed after age 65 will have asprimary coverage either Medicare or the Health Plan program provided by his/her employer or group,depending on the size of the group. This also applies to the over-65 spouse of an active employeewho is a member of the Health Plan.Once a Health Plan member is no longer an active employee or spouse of an active employeeof a Health Plan group, Medicare coverage becomes primary.When Medicare is primary and the Health Plan is secondary, the Health Plan will pay up to the HealthPlan’s fee schedule.No-Fault ClaimsThe Health Plan will deny a claim that was previously rejected by a no-fault insurance carrier if thecarrier’s rejection was based on the carrier’s independent medical examination. The Health Plan willsend a letter of inquiry to the member to determine the status of his/her injuries. The Health Plan willdeny related claims until the member sends a written response.Payment and Other Party Liability (OPL)The Health Plan reviews claims to determine the primary and/or secondary payor. The Health Planmay generate a COB questionnaire to help determine the coordination of benefits payment order.To balance the amounts on secondary claims, the Health Plan requires the following figures from theprimary carrier’s EOB:

• Charges• Allowed amount• Deductible and coinsurance applied• Reduction of charges taken• Payment amount• Patient responsibility

Note: If the Health Plan cannot balance the figures submitted, the claim will bedenied until actual EOB information is provided.

If it is determined that the Health Plan is the primary carrier, the Health Plan will process the claimand make payment for the covered services provided in accordance with the fee schedule.

If the Health Plan is determined to be the secondary carrier, and no primary carrier paymentinformation was submitted with the claim, the Health Plan will deny the claim. Providers shouldresubmit these denied claims to the primary carrier. After the primary carrier has made payment,the provider should resubmit the claim to the Health Plan for consideration of any balances due.

8.5.7 Inquiring about the Status of a ClaimProviders may use one of the inquiry systems described in Section 2 of this manual to inquire aboutthe status of a claim, or they may call Provider Service.


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8.6 RemittanceA participating physician who submits claims for Health Plan benefits plans receives a remittanceadvice that summarizes all claims processed since the last payment was made to the submitter. TheHealth Plan uses two different computer systems for adjudicating claims. Claims for Health Planmanaged care plans are processed on one system, and claims for indemnity plans are processed onthe other. As a result, there are slight differences in the look and information included on remittancesfor managed care and indemnity plan members.

Note: Remittances may come in multiple envelopes. This occurs when a remittanceexceeds the number of pages that the Health Plan’s remittance processing system isable to mail in a single envelope.

8.6.1 When Additional Information is RequiredFor some claims, the Health Plan may need additional information before it can make a determinationto cover or deny the service. These claims will be so marked on the remittance with a message askingthe submitter to provide additional information. A provider has 45 days from the date printed on theremittance to submit supporting documentation related to the service in question.

8.6.2 Understanding the RemittanceIncluded at the end of this Section 8 is a sample remittance advice (for professional claims) for eachclaims processing system. A chart defining the names of the fields on the remittance advice precedeseach sample.

8.6.3 Electronic Remittance Advice and Electronic Funds TransferThe Health Plan has contracted with a vendor to make electronic remittance advice (ERA) andelectronic fund transfer (EFT) available free of charge to providers. At the time of this writing, thevendor is PaySpan Health. Providers who have not received registration codes and instructions toapply for ERA and EFT may contact Trading Partner Support.Valuable benefits of ERA and EFT include: Reduced accounting expenses – Import electronic remittance advice from the Web directly into

Practice Management or Patient Accounting Systems, eliminating the need for manual re-keying. Prompt match of payments to remit advice – Immediately associate electronic payments with

electronic remittance advice. View remittance advice online and print it at your convenience. Increased reporting functionality– Ability to create functional reports that support your internal

needs. Improved cash flow – Electronic payments can mean faster payments, leading to improved cash

flow. Upon enrollment, paper checks will be discontinued. Control over bank accounts – Maintain total control over the destination of claim payment funds.

Multiple practices and accounts are supported.


May 2007 8—15

Manage multiple payers – Reuse enrollment information to connect with multiple payers. Assigndifferent payers to different bank accounts, as desired.

Information and a link to PaySpan Health are on the Health Plan Web site.https://www.excellusbcbs.com/providers/administration/billing_resources/electronic_payment.shtml

8.7 Requesting a Change in Claims PaymentThere are a number of circumstances after a claim has been processed that may require the HealthPlan to take another look. These include incorrect payments or denials, or services billed incorrectly orin error.

8.7.1 AdjustmentsThe Health Plan has a claims adjustment process that providers can initiate after the claim has beenprocessed.Please note that claims returned to the submitter because they were inaccurate or incompletehave not been processed and consequently cannot be adjusted. This includes electronicallysubmitted claims that don’t pass edits at the clearinghouse or payor system. In addition, the HealthPlan cannot adjust a claim when the dollar amounts change due to the provider’s corrections (such asadding a service line or a modifier). A corrected claim must be submitted.Policies The Health Plan will make adjustments when a claim is paid incorrectly due to Health Plan error,

but only if the original claim was “clean.” If the Health Plan mistakenly underpays a provider for a claim, the Health Plan will make an

adjustment on a subsequent remittance. The Health Plan calculates interest on adjustments in accordance with specifications of New York

State prompt payment law. If the Health Plan mistakenly overpays a claim to a participating provider, the Health Plan will

make an adjustment and deduct that amount from future payments.

Note: Providers may also return overpayments to the Health Plan. See the paragraphbelow headed Overpayments.

Review of a claim does not guarantee a change in payment disposition.

ProcedureAdjustments may be requested via: Web Site. Participating providers who are registered users of the Health Plan’s Web site may

request an adjustment electronically via an interactive form available on the Health Plan Web site.Providers may also submit related additional information, such as medical records, electronically.From the Provider page, select Online Services and then, from the menu on the side, selectClaims. Choose Request Claim Adjustment.


8—16 May 2007

QuickLink. Participating Health Plan providers may request adjustment via QuickLink, the HealthPlan’s dial-up application. Providers must be registered for the application. (See Section 2 forinformation about registering for QuickLink.)

Paper Request for Research/Claim Adjustment form. This form is available on the HealthPlan’s Web site or from Provider Service. Attach a copy of the remittance advice that included theclaim, a copy of the original claim form, and other relevant supporting documentation.If a claim was denied for no authorization, but there was an authorization, the provider can usethe Request for Research/Claim Adjustment form and attach a copy of the authorization.The Request for Research/Claim Adjustment form is not appropriate for questioning editsmade by our electronic claim review system or for questioning DRG reimbursement. Seeparagraphs below that address these issues.

Provider Service. Representatives may be able to take information over the phone to initiate anadjustment. If documentation is required, provider may be advised to use the Request forResearch/Claim Adjustment form.

8.7.2 Clinical Editing Review RequestsFor certain claims, the Health Plan’s claim systems may have determined that a procedure wasmutually exclusive (or incidental) to a primary procedure. The Request for Research/ClaimAdjustment form is not appropriate for questioning the results of electronic claim review.Instead, providers should use the Clinical Editing Review Request process described earlier in thissection of the manual.

8.7.3 OverpaymentsThe Health Plan has a process for receiving returned overpayments in lieu of an adjustment on asubsequent claim. In order to properly credit the returned payment, the Health Plan requires the claimnumber, member or subscriber ID, and the date of service. Providers may supply this informationseparately or by including a copy of the applicable remittance.Do not return overpayments for claims involving NYHCRA pools. Notify the Health Plan in writing andinclude a copy of the remittance in question so that the Health Plan can initiate a retraction.Overpayments must be mailed directly to the Credit and Collection Department. (See theContact List in Section 2 of this manual for the correct address for this department.) The process andaddress are also available on the Health Plan’s Web site, as well as from Provider Service.https://www.excellusbcbs.com/providers/administration/billing_resources/overpayment_procedures.shtml


May 2007 8—17

8.7.4 DRG Review RequestIf a hospital needs the Health Plan to review the DRG reimbursement it received on a specific claim(or claims), it should use the DRG Review Request Form, available on the Health Plan’s Web site orfrom Provider Service.Please use this form only for paid claims that require review of the DRG paid versus the DRGsubmitted, or if you are questioning our DRG payment calculations. As stated on the form, theprovider must also include a DRG calculation sheet and copy of the claim submittal (UB-04 or papercopy of electronic equivalent) with the form.

8.8 Charts, Forms and SamplesThe charts, forms and samples listed below are presented on the following pages. Chart: Tips for Accurate and Complete ICD-9-CM Diagnosis Coding Chart: CMS-1500 Field Descriptions Chart: UB-04 Field Descriptions Sample: Managed Care Professional Remittance Advice Chart: Managed Care Remittance Field Descriptions Sample: Professional Remit from Indemnity System Chart: Indemnity Remittance Field Descriptions


8—18 May 2007

Tips for Accurate and Complete ICD-9-CM Diagnosis Coding• Review the Patient’s Medical Record

Maintain patient medical records in keeping with Health Plan standards (see Section 2). Identify the main reason for the patient’s visit. Locate other conditions and confirmed diagnoses that are related to the reason for the

visit. Do not include conditions that are described as “to rule out,” “possible” or “suspected.” Code only those conditions that are supported by clinical medical record documentation.

• Find the Condition in the ICD’s Alphabetical Index The Index lists conditions in alphabetical order. Locate a term for each condition listed in the medical record. For each term located, examine subterms under the main condition term(s) to find the

closest description of the condition. More than one term may be required to fully describethe condition.

Find the appropriate diagnosis code(s) associated with all documented conditions.

• Look up the Diagnosis Code(s) from the Index on the ICD-9’s Tabular List The Tabular List, which appears along the edges of each page, presents the diagnosis

codes in numeric order. Find the main diagnosis code category for each documented condition.

• Read all Definitions and Notes Presented with Each Code Category Follow all cross-reference notes, inclusion notes and exclusion notes.

• Select Diagnosis Codes of the Highest Specificity Possible Select a three-digit code only if there are no four-digit codes within the code category. Select a four-digit code only if there are no five-digit codes within the code category. Select a five-digit code whenever it exists. If the code has a fourth digit of .8 (NEC, “not elsewhere classified”) or .9 (NOS, “not

otherwise specified”), refer back to the medical record to see if other more specific codesin this code category may apply.

• Determine if Any of the Conditions May Be Combined Also determine if some conditions are actually symptoms of another condition and

therefore are not to be coded.

• Record the Diagnosis Codes on the Claim Form First, list the diagnosis code chiefly responsible for the service(s) provided. Then list codes for all other conditions that are documented in the medical record for the

date of service. Report all secondary diagnoses that affect clinical evaluation, management or treatment. Report all relevant V codes and E codes pertinent to the service(s) provided.


May 2007 8—19

CMS-1500 (08-05) Field DescriptionsSee key at the end of this chart.

FieldNo. Name Entry

N/ABlank open area between 1500Health Insurance Claim Form andvertically printed CARRIER

Enter name and address of payor to whom claim is being sent.

1. (Type of health insurance coverage) Check the box OTHER for HMOs, commercial insurance, etc.

*1a. Insured’s ID Number Enter the ID number (number assigned by the Health Plan) ofthe subscriber (person who holds the policy).

*2. Patient’s Name (Last, First, MI) Enter name of person who received treatment or supplies, inorder indicated on form.

*3. Patient’s Birth Date/Sex Enter patient’s date of birth in order indicated on formMM/DD/YYYY - and check M or F (to indicate male or female).

*4. Insured’s NameEnter the name of the person holding the insurance coverage, inorder indicated on form. This is the individual whose ID is enteredin field 1a.

*5. Patient’s Address Enter the patient’s box number or street, city, state, zip code andtelephone no. (if available).

6. Patient Relationship to Insured Mark the appropriate box.

7. Insured’s Address Enter the insured’s box number or street, city, state, zip code andtelephone no. (if available).

8. Patient Status Check only one box per line to describe the patient’s marital andemployment or student status.

*9. Other Insured’s Name If there is other insurance (Field 11d), enter the name (in orderindicated) of the person who holds the other insurance.

*9a. Other Insured’s Policy or GroupNumber

If there is other insurance (Field 11d), enter the policy or groupnumber of the other insurance.

*9b. Other Insured’s Date of Birth/Sex If there is other insurance (Field 11d), enter the date of birth andsex of the person who holds the other insurance.

*9c. Employer’s Name or School Name If there is other insurance (Field 11d), enter the name of theemployer or school that offers the other insurance.

*9d. Insurance Plan Name or ProgramName

If there is other insurance (Field 11d), enter the name of the otherinsurance or program.

*10a. Is Patient’s Condition Related toEmployment?

Check YES or NO to indicate whether the patient’s condition isrelated to employment.


8—20 May 2007


FieldNo. Name Entry

*10b. Is Patient’s Condition Related to anAuto Accident?

Check YES or NO to indicate whether the condition is related to anauto accident. If Yes, enter two-letter postal code of state in whichaccident occurred.

*10c. Is Patient’s Condition Related toAnother Accident?

Check YES or NO to indicate whether the condition is related tosome other kind of accident.

10d. Reserved for Local Use Not used.

*11. Insured’s Policy Group or FECANumber

If known, indicate the policy, group or FECA (Federal EmployeesCompensation Act) number of the individual named in field 4.

11a. Insured’s Date of Birth/Sex Enter the insured’s date of birth and check M or F.

11b. Employer Name or School Name Enter the name of the employer or school through which theinsured obtains his/her insurance.

11c. Insurance Plan Name or ProgramName Enter the name of the insured’s health insurance plan or program.

*11d. Is there another Health Benefit Plan? Check YES or NO to indicate whether the patient has otherinsurance. If Yes, complete info in boxes 9 a through d.

*12. Patient’s or Authorized Person’sSignature

Enter the phrase SIGNATURE ON FILE, or include legal signature(and date) of patient or authorized person.

*13. Insured’s or Authorized Person’sSignature

Enter the phrase SIGNATURE ON FILE, or include legal signature ofinsured or authorized person. If neither, may leave blank or stateno signature on file.

14. Date of Current: Illness, Injury,Pregnancy (LMP)

For illness, enter the onset date (acute medical emergencyonly). For injuries, enter the date of the accident. Forpregnancy, enter the date of the last menstrual period (LMP).

15. If Patient Has Had Same or SimilarIllness, Give First Date

Enter the first date the patient had the same or similar illness. Donot include previous pregnancy.

16. Dates Patient Unable to Work inCurrent Occupation

Enter the From/To dates that the patient was unable to work, in theorder indicated on the form.

*17. Name of Referring Provider or OtherSource

When applicable, enter the name of the referring, ordering orsupervising provider.

*17a. Blank shaded areas for other IDnumber.

Blank shaded areas for qualifier and other ID numbers whenapplicable. Use qualifier “1B” (indicates Blue Shield number),followed by the non-NPI provider number. Do NOT include non-NPIprovider number after May 22, 2008.


May 2007 8—21


FieldNo. Name Entry

17b. NPI When applicable, enter the national provider identifier (NPI)number of the referring, ordering or supervising provider.

*18. Hospitalization Dates Related toCurrent Services

This field is used for medical services furnished as a result of,or subsequent to, a related hospitalization. Enter theadmission and discharge dates of hospitalization associatedwith the current services. If discharge has not yet occurred,leave the TO date blank.

19. Reserved for Local Use Not used.

20. Outside Lab? $ChargesIf applicable, check the appropriate box and enter the charges. IfYES is checked, enter appropriate information in field 32 (servicefacility location information).

*21. Diagnosis or Nature of Illness orInjury

Enter the appropriate diagnosis code(s). Include 4 or 5 digits(highest level of specificity) where appropriate.

22. Medicaid ResubmissionCode/Original Ref. No. Not used by Health Plan.

23. Prior Authorization Number If applicable, enter the referral or prior authorization numberassigned by the Health Plan.

24.NOTE: Shaded lines in item 24 A-J are not service lines. They are for supplemental info (such as narrativedescription of an unspecified code) and to allow for submission of the non-NPI provider number (shadedarea of 24J). Do NOT include non-NPI provider number after May 22, 2008.

*24A. Dates of ServiceEnter the date(s) of service applicable to each procedure,service or supplies. If one date of service only, either leave TOblank or enter same date as FROM.

*24B. Place of Service

Enter the appropriate CMS Place of Service (POS) codedescribing the place where the service was rendered. Place ofservice codes are available from CMS athttp://www.cms.hhs.gov/PlaceofServiceCodes/Downloads/placeofservice.pdf

24C. EMG Place a Y in this field for accidental injury or medical emergencyservices rendered in an office setting. Otherwise, leave blank.

*24D. Procedures, Services or SuppliesEnter the appropriate CPT/HCPS code(s) and associatedmodifier(s) (if appropriate) specific to the procedure, serviceor supply item provided. If billing anesthesia, include start andstop times in the shaded area.


8—22 May 2007


FieldNo. Name Entry

*24E. Diagnosis PointerEnter the diagnosis code reference number associated with eachprocedure, service, or supply item listed in field 21. This is the linenumber from field 21 that relates to the reason for the service.

*24F. Charges Enter the charge for each procedure, service, or supply itemlisted.

*24G. Days or UnitsAs applicable, enter the number of days or units (such asanesthesia) associated with each procedure, service, or supplyitem listed.

24H. EPSDT Family Plan This field is to show whether the service was provided under thefederal Early & Periodic Screening, Diagnosis & Treatment benefit.

24I. ID. QUAL. In shaded area, enter “1B” (designates Blue Shield providernumber).

*24J. Rendering Provider ID

• Shaded area (top): Enter current rendering provider ID no.(non-NPI number) until further notice from Health Plan. DoNOT include non-NPI provider number after May 22, 2008.

• Non shaded area (bottom): Enter national provider identifier(NPI) number. If rendering provider is the same for all lines ofthe claim, it is acceptable to enter the NPI on the first claimline only and leave the others blank.

*25. Federal Tax I.D. Number (SSN/EIN)Enter the Federal Tax I.D. (employer identification number orsocial security number) of the group, PC or provider andcheck the appropriate box.

26. Patient’s Account Number Enter the provider’s account number for the patient. If billing forearly intervention services, enter “EIP” preceding account number.

27. Accept Assignment? Indicates whether provider agrees to accept assignment under theterms of the Medicare Program.

*28. Total Charge Enter the total of all charges listed on all lines in field 24F.

*29. Amount Paid When applicable, enter the amount paid by the patient or otherpayors.

*30. Balance Due When available, enter the balance due.

*31. Signature of Physician or SupplierIncluding Degrees or Credentials

Enter the phrase SIGNATURE ON FILE, or include legal signature ofpractitioner or supplier (or representative), including title.

32. Service Facility Location InformationIf the services were provided at a location different from theaddress specified in field 33, enter the name and address of thatlocation here.


May 2007 8—23


FieldNo. Name Entry

32a. NPI If different from billing provider, enter the national provider identifier(NPI) number of service facility given in field 32.

32b. Blank shaded areaIf different from billing provider, until further notice from HealthPlan, enter the two-digit qualifier “1B” (designates Blue Shieldprovider number) followed by the non-NPI provider ID number.

33. Billing Provider Info & PH # Enter the provider’s or supplier’s billing name, address (includingzip code) and telephone number.

33a. NPI Enter the national provider identifier (NPI) number of thebilling provider in field 33.

33b. Blank shaded areaUntil further notice from Health Plan, enter “1B” (designates BlueShield provider number) followed by current billing provider ID(non-NPI). Do NOT include non-NPI provider number after May 22,2008.

KEY• Bolded field indicates that claim cannot be processed if information in these fields is missing,

illegible or invalid. Claim will reject at front end.• * (asterisk) indicates information listed in New York State Insurance Department (NYSID) claim

submission guidelines. The Health Plan cannot reject as incomplete a claim submitted on a CMS-1500 claim form if the claim contains accurate responses in these fields, unless otherwisespecified. Depending on the type of claim, the Health Plan may not require all the informationdesignated in the NYSID claim submission guidelines.

NOTE: The Health Plan requires information in certain other fields before it can adjudicate theclaim. These fields may vary with the type of service being billed. Completion of all fields doesnot guarantee payment.


8—24 May 2007

UB-04 CMS-1450 Field DescriptionsSee notes at the end of this chart.

Field Name Entry

1 Unlabeled 4 lines for Provider Name, Address, Telephone, Fax,Country Code (only if address/phone outside the U.S.)

2 Unlabeled 4 lines for Pay-to Name, Address, etc.

3a PAT CTL # Patient Control Number assigned to patient by provider

3b MED REC # Medical record number assigned to patient’s medicalrecord by provider

4 TYPE OF BILL4-digit code that identifies type of facility, billclassification (variations for hospital, clinic or specialfacilities), and frequency (indicates sequence of billin particular episode of care).

5 FED. TAX NO. Tax identification number (TIN) or employeridentification number (EIN)

6 STATEMENT COVERS PERIOD(From/Through)

Enter beginning and ending dates of the periodincluded on the claim

7 Unlabeled (2 lines) 2 lines – not used

8a PATIENT NAME - ID Patient ID number (depending on primary, secondary,tertiary in field 60)

8b PATIENT NAME Enter name of patient

9 PATIENT ADDRESSLines a through e for street and number or box number,city, state, zip code and country code (if address outsidethe U.S.)

10 BIRTHDATE Enter patient’s date of birth11 SEX Enter F or M12 ADMISSION DATE Date of admission or commencement of services13 ADMISSION HOUR Time of day of admission or commencement of services

14 ADMISSION TYPE Appropriate code for emergency, urgent, elective,newborn, etc.

15 ADMISSION SRC Source of admission code

16 DHR Discharge hour

17 STAT Patient discharge status code

18-28 CONDITION CODES Relate to type or lack of coverage


May 2007 8—25


Field Name Entry29 ACDT STATE Accident state

30 Unlabeled (2 lines) Not used – 2 lines

31-34 OCCURRENCE CODE and DATE Enter applicable occurrence code(s) and associated datein lines a and b

35-36 OCCURRENCE CODE and SPAN(FROM/ THROUGH)

Enter applicable occurrence code(s) and associated datespan in lines a and b

37 Unlabeled Unused – lines a and b

38 Unlabeled 5 lines for responsible party/subscriber name andaddress

39-41 VALUE CODES and AMOUNTS (lines athrough d)

Lines a through d. Value codes and amounts, includingthose for covered days (80), non-covered days (81),coinsurance days (82) or lifetime reserve days (83)should be placed here.

42 REV CODE Revenue code for each service billed – 22 lines

43 DESCRIPTION Revenue code description for each service billed – 22lines

44 HCPCS / RATE / HIPPS CODE HCPCS or HIPPS code corresponding to each servicebilled – 22 lines

45a SERV. DATE Service date of each service billed – 22 lines45b CREATION DATE Date claim form is completed

46 SERV. UNITS Service units corresponding to each service billed – 22lines

47 TOTAL CHARGES Total charges for each service billed – 22 lines48 NON-COVERED CHARGES Non-covered charges for each service billed – 22 lines

49 Unlabeled 22 lines – not used

47-48 TOTALS Total amount of charges and total amount of non-coveredcharges

50 PAYER NAME 3 lines, one each for primary, secondary and tertiarypayers.

51 HEALTH PLAN ID3 lines, one each for primary, secondary and tertiarypayers. Current non-NPI provider number. Required byHealth Plan until notified. Do NOT include non-NPIprovider number after May 22, 2008.


8—26 May 2007


Field Name Entry

52 REL INFORelease of information certification indicator (Y or I). 3lines, one each for primary, secondary and tertiarypayers.

53 ASG BEN Assignment of benefits certification indicator. 3 lines, oneeach for primary, secondary and tertiary payers.

54 PRIOR PAYMENTS Payments from other payers or patient. 3 lines, one eachfor primary, secondary and tertiary payers.

55 EST. AMOUNT DUE Estimated amount due from patient. 3 lines, one each forprimary, secondary and tertiary payers.

56 NPI NPI for billing provider.

57 OTHER PRV IDOther provider identifier (non-NPI assigned by HealthPlan). 3 lines, one each for primary, secondary andtertiary payers. Do NOT include non-NPI provider numberafter May 22, 2008.

58 INSURED’S NAME Name of holder of the insurance contract. 3 lines, oneeach for primary, secondary and tertiary payers.

59 P REL Patient’s relationship to insured. 3 lines, one each forprimary, secondary and tertiary payers.

60 INSURED’S UNIQUE ID Insured’s insurance identification number. 3 lines,one each for primary, secondary and tertiary payers.

61 GROUP NAME Insured’s group name. 3 lines, one each for primary,secondary and tertiary payers.

62 INSURANCE GROUP NO. Insured’s group number(s), if available. 3 lines, one eachfor primary, secondary and tertiary payers.

63 TREATMENT AUTHORIZATIONCODES

Health Plan authorization number. 3 lines, one each forprimary, secondary and tertiary payers.

64 DOCUMENT CONTROL NUMBER Area for Health Plan to assign claim number

65 EMPLOYER NAME Insured’s employer name. 3 lines, one each for primary,secondary and tertiary payers.

66 DX Qualifier code reflecting ICD revision. Enter 9 for 9th

Revision.

67 Label is 67 Enter principal diagnosis code. Include all digits (4-5)where applicable


May 2007 8—27


Field Name Entry

67 A through Q Other diagnosis codes. Include all digits (4-5) whereapplicable.

68 Unlabeled 2 lines – not used69 ADMIT DX Admitting diagnosis code (if inpatient claim)70 PATIENT REASON DX Patient’s reason for visit (diagnosis) code(s) (3 blocks)

71 PPS CODE Prospective Payment System code

72 ECI External cause of injury code(s) (3 blocks)

73 Unlabeled Input DRG code here.

74 PRINCIPAL PROCEDURE CODE andDATE

Enter principal procedure code and date ofprocedure

74a-e OTHER PROCEDURE CODE and DATE As applicable, enter other procedure codes and dates

75 Unlabeled 4 lines - not used

76 ATTENDING – NPI, QUAL, LAST,FIRST

5 boxes. Enter NPI of attending provider and last and firstnames of attending provider

77 OPERATING – NPI, QUAL, LAST,FIRST

5 boxes. Enter NPI of operating provider and last and firstnames of operating provider

78 OTHER – NPI, QUAL, LAST, FIRST 5 boxes. Enter NPI of other provider and last and firstnames of other provider

79 OTHER – NPI, QUAL, LAST, FIRST Same as above

80 REMARKS 4 lines for notation that doesn’t go elsewhere

81 CC Code-Code (lines a through d, 3 boxes each)

81a Taxonomy code qualifier and taxonomycode(s)

In first box, enter qualifier code B3 for field 56 billingprovider taxonomy code. In second (and third, ifapplicable) boxes, enter taxonomy code(s) for the field 56billing provider.

81b Other code qualifier and other code As needed

81c Other code qualifier and other code As needed

81d Other code qualifier and other code As neededNOTE: Bolded field indicates that claim cannot be processed if information in these fields is missing,illegible or invalid. Claim will reject at front end.NOTE: The Health Plan requires information in certain other fields before it can adjudicate the claim. Thesefields may vary with the type of service being billed. Completion of all fields does not guarantee payment.


8—28 May 2007

Managed Care Remittance Field DescriptionsHMO, POS, Medicare Advantage, Healthy New York (A), Child Health Plus, Family Health Plus andMedicaid managed care claims

Header InformationRemittance Address Payee’s remittance address

PROVIDER NAME Payee’s name

PROVIDER NO. Provider’s managed care ID number assigned by Health Plan. Links to tax ID below.

TAX ID Federal tax identification number printed on the claim

[Product Type] If present, prints in center under “Remittance Advice” and represents the name of the product(example: Blue Point 2)

PAYABLE DATE Date remittance advice was produced

SERVICE PROVIDER Number of servicing provider (assigned by Health Plan)

REFERENCE CODE Code representing the health benefit program (product)

Claim InformationIn addition to the fields below, messages regarding a specific claim line (if any) may appear immediately below theclaim line in question. Messages regarding the entire claim (if any) may appear immediately below the claim total line.MEMBER NAME Patient’s name.

MEMBER NO Health Plan-assigned number of patient who received the service, as shown on member’sHealth Plan ID card.

PROVIDER ACCT NO If present, account number provider has assigned to the patient for the service/date ofservice.

DOB Patient’s date of birth.

CLAIM NO Number Health Plan assigns claim upon receipt.

AUTHORIZATION NO If present, the authorization number assigned by the Health Plan for referral orpreauthorization of service.

LOC Internal use only. The processing system converts the place of service code to a smaller listused by the Health Plan.

SERV Service line number. Used to identify multiple services billed on one claim.

DATE Date of service. Shown as a date span.

DIAG Diagnosis code.

PROC Procedure code.

CHARGED Amount billed.

ALLOWED Maximum amount payable according to subscriber contract and the Health Plan fee schedule.


May 2007 8—29

Managed Care Remittance Field DescriptionsHMO, POS, Medicare Advantage, Healthy New York (A), Child Health Plus, Family Health Plus andMedicaid managed care claims

EXPL Explanation code. Used to relay information about the claim to the provider. EXPL codes aredefined on last page of remittance advice.

DENIED Dollar amount (if any) not reimbursable by the plan.

OUTLR Field used on hospital remittance advice only. Shows amounts outside the normal DRGamount (i.e., higher than normal).

COPAY Dollar amount due from the member (e.g., copayments, coinsurance or member penalty).

RISK [VALUE POOL]Applies to IPAs only and includes withhold and/or administrative fees. (Providers who do notbelong to an IPA should have only zeros in the field.) Do not bill the member for any amountincluded in this field.

DEDUCT Deductible.

OCL Other carrier liability. Amount paid by another insurer as the result of coordination of benefitsbetween two or more health plans.

PAYMENT Dollar amount being paid to the provider.

(Explanation message) A message from the Health Plan regarding the claim line may appear here. Example:Rebundling.

CLAIM TOTAL Total of all service lines reported on an individual claim.

(Claim message) A message from the Health Plan regarding the claim may appear here.Remittance Totals

PROVIDER TOTAL Total of all claims for one specific provider on the remittance. (Remittance may includemultiple providers if services are submitted under a group practice.)

STATEMENT TOTALS Total of all claims for all providers on the remittance. (Remittance may include multipleproviders if services are submitted under a group practice.)

PREVIOUS BALANCE Any balance due to the Health Plan prior to this remittance.

CURRENT BALANCE Current balance on this remittance.

TOTAL AMOUNTSUPPRESSED

Dollar amount deducted from this remittance to take back payment as the result of a claimthat was previously adjusted. (This field would also be used if the provider’s reimbursementarrangement includes capitation, or for a hospital that receives regular payments withreconciliation at year-end.)

NET AMOUNT PAID Total payment less any amounts adjusted or suppressed.

ExplanationsThis section of the remittance advice includes definitions of any explanation (EXPL) codes (including denials)appearing in the claim information section. It may also include messages, including messages regarding adjustments.

NANCY DOCTOR MD PAGE # 1123 MAIN STREET PAYABLE DATE : 11/2/2000ANYTOWN NY 00000 SERVICE PROVIDER: P0123456789

REFERENCE CODE : [product line code]PROVIDER NAME: NANCY DOCTOR MD

PROVIDER NO: G000000000TAX ID: 00123456789

-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------MEMBER NAME: JOHN SMITH MEMBER NO: 1234A6789 01 PROVIDER ACCT NO: 1234 DOB 05-17-1963CLAIM NO: 01 06577027900 AUTHORIZATION NO: LOC 02

SERV DATE DIAG PROC CHARGED ALLOWED EXPL DENIED OUTLR COPAY RISK DEDUCT OCL PAYMENT0100 05/02-05/02/06 07810 17110 75.00 65.00 0.00 0.00 20.00 0.00 0.00 0.00 45.000200 05/02-05/02/06 6961 9921225 40.00 35.00 0.00 0.00 0.00 0.00 0.00 0.00 35.000300 05/02-05/02/06 6961 96910551 25.00 0.00 CC6 25.00 0.00 0.00 0.00 0.00 0.00 0.00 THIS LINE HAS BEEN REBUNDLED TO LINE 0040400 05/02-05/02/06 6961 96910 25.00 24.00 0.00 0.00 0.00 0.00 0.00 0.00 24.00 THIS LINE HAS BEEN ADDED DUE TO REBUNDLING

-------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- ---------------------- CLAIM TOTAL: 140.00 124.00 0.00 0.00 20.00 0.00 0.00 0.00 104.00

-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------MEMBER NAME: MARY JONES MEMBER NO: 1234B5678 02 PROVIDER ACCT NO: 528 DOB 01-01-1949CLAIM NO: 01 0657702880 AUTHORIZATION NO: LOC 03

SERV DATE DIAG PROC CHARGED ALLOWED EXPL DENIED OUTLR COPAY RISK DEDUCT OCL PAYMENT0100 10/02-10/02/00 6825 99215 65.00 0.00 RBL 65.00 0.00 0.00 0.00 0.00 0.00 0.00 THIS LINE HAS BEEN REBUNDLED TO LINE 002 PROCEDURE 114210200 10/02-10/02/00 6825 11421 182.00 103.84 0.00 0.00 15.00 6.66 0.00 0.00 82.180300 10/02-10/02/00 6825 82948 4.50 4.50 0.00 0.00 0.00 0.34 0.00 0.00 4.16

-------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- ---------------------- CLAIM TOTAL: 186.50 108.34 65.00 0.00 15.00 7.00 0.00 0.00 86.34

========= ========= ========= ========= ========= ========= ========= ========================== PROVIDER TOTAL: 326.50 232.34 65.00 0.00 35.00 7.00 0.00 0.00 190.34

STATEMENT TOTALS 326.50 232.34 65.00 0.00 35.00 7.00 0.00 0.00 190.34

PREVIOUS BALANCE 0.00CURRENT BALANCE 0.00TOTAL AMOUNT SUPPRESSED 0.00

NET AMOUNT PAID 190.34 ON CHECK NUMBER 1234567

CC6: SERVICE SHOULD BE BILLED WITHOUT MODIFIER 51. SEE ADDED LINE.RBL: DENIED - SERVICE COMBINED WITH ANOTHER SERVICE LINE

SAMPLE MANAGED CARE PROFESSIONAL REMITTANCE ADVICE

REMITTANCE ADVICE

[PRODUCT NAME]

165 Court Street, Rochester, New York 14647


May 2007 8—31

Indemnity/PPO Remittance Field Descriptions(Professional Claims)

For PPO, EPO, Healthy New York (B) EPO, ValuMed and indemnity product claims

Header InformationPROVIDER ID Provider’s indemnity ID number assigned by Health Plan.

Provider name/ address Payee’s name and remittance address.

PROCESS DATE/TIME Date/time remittance advice was produced.Claim Information

In addition to the fields below, messages regarding a specific claim line (if any) may appear immediately below theclaim line in question. Messages regarding the entire claim (if any) may appear immediately below the claim total line.

SUBSCRIBER ID For this claim, the Health Plan-assigned number of patient who received the service, asshown on Health Plan ID card.

CLAIM ID Number Health Plan assigns claim upon receipt.

PATIENT NAME LAST/FIRST Patient’s last and first names as shown on claim.

PATIENT ACCOUNT# If specified on the original claim, account number provider has assigned to the patient for theservice/date of service.

PROCEDURE CODE Procedure code.

SERVICE START Date reported on original claim.

SERVICE END Date reported on original claim.

CLAIMS CHARGES Amount billed.

ALLOWED AMOUNT Maximum amount payable according to subscriber contract and Health Plan fee schedule.

BENEFIT ALLOWANCE Maximum amount payable according to subscriber contract and Health Plan fee schedule.

REIMBURSED AMOUNT Dollar amount being paid to provider.

PATIENT LIAB Amount provider can bill patient.

(Service line message) A message from the Health Plan regarding the claim line may appear here. Example: Themessage Basic Coverage will appear here if the service was paid at the basic benefit level.

CLAIM TOTAL Total of all service lines reported on an individual claim.

(Claim status message) Indicates status of the claim. Examples: PAID or NON-COVERED.

(Claim message) A message from the Health Plan regarding the claim may appear here.Remittance Totals

PAID CLAIM TOTALS Shows totals for various categories of payment or non-payment included in this remittance,including PAID, NET ADJUSTMENTS, NON-COVERED, MEMBERSHIP DENIAL.

UNITS Sum totals for each category of payment or non-payment on this remittance.


8—32 May 2007

Indemnity/PPO Remittance Field Descriptions(Professional Claims)

For PPO, EPO, Healthy New York (B) EPO, ValuMed and indemnity product claims

CHARGES Total charges for each category of payment or non-payment for all service items included onthis remittance.

ALLOWED Totals of allowed amounts, or maximum amounts payable according to the Health Plan feeschedule, for each category of payment or non-payment included on this remittance.

BENEFIT ALLOWANCE Total benefit amounts, or maximum amounts payable according to the Health Plan feeschedule, for each category of payment or non-payment included on the remittance advice.

REIMBURSABLE Total of all amounts included on the remittance advice that the Health Plan is paying.

PATIENT LIAB Total of all amounts included on the remittance advice that the provider may bill to the patient.

CLAIM COUNT Total number of claims included on the remittance advice.

PROCESS DATE/TIME PAGE06/06/2006 06:53 1

PROVIDER ID 123456 RICHARD DOCTOR MD ANY FACILITY

SUBSCRIBER ID PATIENT NAME PATIENT PROCEDURE SERVICE SERVICE CLAIMS ALLOWED BENEFIT REIMBURSED PATIENTCLAIM ID LAST/FIRST ACCOUNT# CODE START END CHARGES AMOUNT ALLOWANCE AMOUNT LIAB

ZFA1234B6789-1 POO ABC56789 99213 05/04/06 05/04/0699999999992 WINNIE 60.00 50.00 50.00 30.00 20.00

PRICED AT OUR SCHEDULE OF ALLOWANCEALLOWANCE REDUCED BY $20 COPAYMENT

"PAID" CLAIM TOTAL 60.00 50.00 50.00 30.00 20.00------------------------------ ----------------------- ---------------- --------------------- --------------- -------------- --------------- ---------------- -------------------- ---------------------- -------------------SXL1ABC23456-1 BAGGINS ABC23456 99215 05/10/06 05/10/06

99999999993 BILBO 175.00 150.00 150.00 130.00 20.00PRICED AT OUR SCHEDULE OF ALLOWANCEHOME PLAN BLUE CARD COPAYMENT APPLIED

93000 05/10/06 05/10/0650.00 30.00 30.00 30.00 0.00

PRICED AT OUR SCHEDULE OF ALLOWANCE"PAID" CLAIM TOTAL 225.00 180.00 180.00 160.00 20.00

------------------------------ ----------------------- ---------------- --------------------- --------------- -------------- --------------- ---------------- -------------------- ---------------------- -------------------SXL2ABC34567-1 BAGGINS ABC34567 80100 05/10/06 05/10/06

99999999994 FRODO 20.00 0.00 0.00 0.00 20.00CONTRACT DOES NOT ALLOW COVERAGE FOR THIS BENEFIT

**NON-COVERED** CLAIM TOTAL 20.00 0.00 0.00 0.00 20.00

PAID CLAIM TOTALS UNITS CHARGES ALLOWED BENEFIT ALLOWANCE REIMBURSABLE PATIENT LIAB CLAIM COUNTPAID 3 285.00 230.00 230.00 190.00 40.00 3

NET ADJUSTMENTS 0 0.00 0.00 0.00 0.00 0.00 0NON-COVERED 1 20.00 10.00 10.00 0.00 20.00 1

MEMBERSHIP DENIAL 0 0.00 0.00 0.00 0.00 0.00 0TOTAL 3 305.00 240.00 240.00 190.00 60.00 4

SAMPLE PROFESSIONAL REMIT FROM INDEMNITY SYSTEM

165 Court Street, Rochester, New York 14647

PHYSICIAN REMITTANCE SUMMARY

123 MAIN STREETANYTOWN NY 00000

Documents

Excellus BlueCross BlueShield Participating … 2007 8—1 Excellus BlueCross BlueShield Participating Provider Manual 8.0 Billing and Remittance This section includes instructions