As of November 1, 2013, we have begun transitioning our IBC membership to the
new operating platform. As a result of the transition, we will be enforcing
industry standards for claims processed on the new platform (including Federal
Employee Program [FEP] members and Host BlueCard
® claims). If
you have been submitting claims based on industry standards, as has been
communicated to you in the past, you will have no issues with the topics noted
below. However, if you have not, please be advised that you will see an
increase in rejections and/or claim denials for claims processed on the new
platform.
These standards include, but are not limited to, the following:
NAIC code. The payer NAIC code must be the same as the claim and
envelope layers? Receiver and Payer codes. In addition, please refer to the
payer ID grids at
www.ibx.com/edi to
ensure that you submit claims with the appropriate NAIC code, as identified in
the Payer Information column and in accordance with the member?s coverage. This
will direct your claims to the correct operating platform for processing.
Interim billing claims. Interim billing claims are not accepted from
acute care facilities for inpatient claims. Acute care facilities are required
to submit claims after the member is discharged.
Occurrence code M0. Occurrence code M0 (zero) must be reported with
Condition Code C3.
Missing procedure description. A description is required for all
non-specific codes (i.e., not otherwise classified [NOC]; unspecified; other;
miscellaneous; prescription drug, generic; or prescription drug, brand name).
Invalid revenue codes. The ?001? revenue code is meant to indicate the
total charge, and it should no longer be submitted at the service line level.
The total charge should only be in the total charge field at the claim level.
Room and board. A room and board revenue code is required for all
inpatient bill types.
NPI/Taxonomy code. The provider?s National Provider Identifier (NPI)
must be billed with the corresponding taxonomy code.
Operating physician requirement. If a claim has a surgical revenue code
with a surgical procedure code, the operating physician is required.
Referring provider. The referring provider is required on all claims
when place of service is 81 (i.e., independent clinical lab) is used.
Professional and ancillary BlueCard® claims. For
professional and ancillary providers who submit claims on the CMS-1500 form or
through the 837P transaction, you must continue to submit commercial BlueCard
claims to Highmark Blue Shield, as this process has not changed. IBC will only
process Medicare Advantage PPO claims.
For more information about our transition to the new platform, please visit the
Business
Transformation section of the IBC Provider News Center. On this site, you
will find a communication archive and Frequently Asked Questions (FAQ)
document. If you still have questions after reviewing the FAQ, email us at
provider_communications@ibx.com.