Claims Reports: Overview

Claims Reports: Overview

Introduction BCBSTX provides explanations of claims handling to you and the patient. There are two reports that may be sent to your office, and they are each described in this section.

In this Section

This section describes the following claims reports:

Report Title Page

Provider Claim Summary for CMS 1500 (08/05) Claims E — 2 Provider Claim Summary for UB-04 Claims E — 7

Provider Claim Summary for CMS Claims

Fields 1-7

Providers receive a Provider Claims Transaction Report listing payments. The following table explains fields 1 through 7 on this report:

Field Number

Field Name Information Provided 1 Document Number A unique number assigned to each

Provider Claims Transaction Report. 2 NPI Number The NPI number. In a clinic or group

practice, the 800,000 number for the provider who performed the service will appear to the right of the patient’s name.

3 Patient Name The patient’s name as reported to BCBSTX.

4 Patient Account # The patient’s account number assigned by the provider as indicated on the claim submitted to BCBSTX. If an account number is not given, this field will be blank.

5 Subscriber Identification The subscriber’s identification number from the ID card.

6 Group # The number that identifies the subscriber’s group.

7 Claim Type This displays the code for the type of claim.

Key for Claim Type

Claim type code definitions:

Code Definition

ADJ Adjustment of a Previously Processed Claim CMC Coordination of Benefits with Managed Care COB Coordination of Benefits

MC Managed Care (optional or no PCP) MCP Managed Care (PCP required)

MR Medicare Primary

REG Regular Business (Indemnity or ParPlan)

Provider Claim Summary for CMS Claims,

Fields 8-12

The following table explains fields 8 through 12 on the Provider Claims Transaction Report:

Field Number

Field Name Information Provided 8 Internal Control A unique number assigned to each

claim as it enters the BCBSTX claims processing system.

9 Service Dates The beginning and ending dates of service indicated on the claim. If the claim contains only one date of service, the “To” field will be blank. 10 POS This indicates the place of service or where the services were performed (e.g., office, inpatient hospital). 11 Type of Service A description of the service(s)

rendered.

12 Proc Code The code from CPT or the BCBSTX conversion code used to identify and report the service performed.

Note on Fields 11 and 12

The fields for type of service (11) and procedure code (12) will only display for detailed line item charges where there is a difference in the total charge and the contract allowable on claims other than Medicare-related, COB, and Adjustments.

Provider Claim Summary for CMS Claims,

Fields 13 -16

The following table explains fields 13 through 16 on the Provider Claims Transaction Report:

Field Number

Field Name Information Provided 13 Total Charges The total charges filed on the claim. 14 Contract Allowable The benefits allowed by the

subscriber’s coverage.

15 MSG Code The message code for the explanation of the difference between the billed charges and the contract allowable for that procedure. Multiple message codes may indicate that the claim was processed with more than one type of coverage or policy. Please see Message Code Explanation (18). 16 Patient’s Share Listing of any copayment, deductible,

cost share (coinsurance), and charges for medically necessary, limited, or noncovered services.

Patient’s Share The subscriber is responsible for no other charges submitted on the claim except for the following:

Patient’s Share Which Includes

Copay/Deductible The amount of copayment and/or deductible taken from the gross allowable charges.

Coinsurance The amount taken from the gross allowable charges and the patient’s portion when contract benefit percentages were applied. This includes the patient’s benefit contract.

Other Medically necessary items not covered or limited by the patient’s benefit contract.

Provider Claim Summary for CMS Claims,

Fields 17 - 19

The following table completes the key to the Provider Claims Transaction Report:

Field Number

Field Name Information Provided 17 Benefit Payment The benefit amount paid by BCBSTX

after any copay, deductibles, cost share, and charges for medically necessary, limited, or noncovered services were deducted for the contract benefit allowable amount. 18 Message Code Explanation of the difference between

the billed charge and the contract allowable for that procedure.

19 Totals Totals for each column for all patients included on the report.

Provider Claim Summary for UB-04 Claims

PROVIDER CLAIM SUMMARY

PROVIDER NUMBER: 0000HH1234 2 CHECK NUMBER: 12345678 3 TAX IDENTIFICATION NUMBER: 123156769 4

5 COUNTY MEDICAL CENTER P. 0. BOX 123456

YOUR CITY, TX. 12345-1234

ANY MESSAGES WILL BEGIN ON PAGE 1 *********** INPATIENT

PATIENT: HORMAN DOE PATIENT NO: 123456789 ADMIT DATE FROM DATE END DATE CLAIM NO: 0000123456789000X CLAIM TYPE: 01/30/05 01/30/05 01/31/05 GROUP-SUB NO: FEPTX-12345678 HPI: D DRG

DAYS DRG PROVIDER OTHER PAYABLE FACILITY ADJUSTED MANAGED CARE TOTAL AMOUNT /TRT CODE CHARGE / WITHHOLD ALLOWABLE PROV. CHARGE DEDUCTION(S) PAID 001 294 $10,816.00 $8,022.01- $2,795.99 $2,795.99 $500.00 $2,195.99

MESSAGES/REASONS: OE , OH , DRG

*** DEDUCTIONS/OTHER INELIGIBLE ***

CONTRACT DEDUCTIBLE/COPAY: $100.00 MANAGED CARE DEDUCTION(S): $500.00 TOTAL DEDUCTIONS/OTHER INELIGIBLE: ___$600.00 PATIENT'S SHARE: ___$600.00

--- PROVIDER CLAIMS AMOUNT SUMMARY

MUMBER OF CLAIMS: 1 | AMOUNT PAID: $2,195.99 PROVIDER CHARGES: $10,618.00 | RECOUPMENT AMOUNT: $0.00 ADJUSTED PROVIDER CHARGES: $2,795.99 | NET AMOUNT AMOUNT: $2,195.99 PATIENT'S SHARE: $600.00 |

--- CLAIM TYPE

--- MESSAGES/REASONS:

(OE ). A CONTRACT DEDUCT I BLE/COPAY HAS BEEN TAKEN.

(OH ). PROGRAM REQUIREMENTS AS IDENTIFIED BY THE MEMBER'S CONTRACT HAVE NOT BEEN FULFILLED. THIS IS THE PATIENT'S LIABILITY.

(DRG). THE PAYMENT ON THIS CLAIM HAS BEEN PROCESSED ACCORDING TO THE OMNIBUS BUDGET RECONCILIATION ACT OF 1990. THE PAYMENT PROVIDED IS THE SAME AS THE PAYMENT YOU WOULD HAVE RECEIVED HAD THE PATIENT BEEN ENROLLED IN MEDICARE PART A. THE PAYMENT IS BASED ON THE MEDICARE DRG PRICE.

THE SUBSCRIBER IS NOT RESPONSIBLE FOR THE DIFFERENCE.

Provider Claim Summary for UB-04 Claims

,

Fields 1-9

The Provider Claim Summary (PCS) is a notification statement sent to contracting providers with Blue Cross and Blue Shield of Texas (BCBSTX) after a claim has been processed. The following table explains fields 1 through 9 on this report:

Field Number

Field Name Information Provided 1 Date Date the summary was finalized.

2 NPI Number NPI Number

3 Check Number Number assigned to the check for this summary.

4 Tax Identification Number Number which identifies provider’s taxable income.

5 Provider or Group Name & Address

The provider/group address where the services were rendered.

6 Patient Name of the individual who received the service.

7 Claim Number The Blue Cross number assigned to the claim.

8 Group-Sub Number Number that identifies the employer group and member.

9 Patient Number The patient’s account number assigned by the provider.

Provider Claim Summary for UB-04 Claims,

Fields 10-19

The following table explains fields 10 through 19 on this report: Field

Number

Field Name Information Provided 10 Claim Type Code for type of claim (benefit plan) –

see field 27.

11 HPI Indicator Blue Cross payment method for this claim. IND DESCRIPTION D DRG B Outpatient DRG Cap W Withhold/Discount R Case Rate E % of charge w/cap F Fee Schedule P Per Diem N Negotiated

C Inpatient Case Rate 12 Admit Date Date if admission.

13 From Date Beginning and ending dates of services rendered.

14 End Date

15 Days/Treatment Number of days/treatment. 16 DRG Code DRG code for this type of service. 17 Provider Charge Total amount of billed charges. 18 Other Payable/Withhold Other payable amounts, such as

discounts or withholds, that affect the adjusted provider charges.

19 Facility Allowable The provider’s allowed amount according to negotiated contract.

Provider Claim Summary for UB-04 Claims,

Fields 20-29

The following table explains fields 20 through 29 on this report: Field

Number

Field Name Information Provided 20 Adjusted Provider Charges The allowed amount including other

payable or withhold.

21 Managed Care Deduction(s) Managed care deductions including penalties, copayments and

coinsurance amounts.

22 Total Amount Paid The amount paid to the provider for this service.

23 Contract Coinsurance The coinsurance/deductible amount applied to this claim.

24 Total Deductions/Other Ineligible

Total deductions and other ineligible amounts.

25 Patient’s Share Amount patient pays. Providers may bill this amount to the patient. 26 Provider Claims Amount

Summary

Total for claim(s) processed on this summary.

27 Claim Type The description for the type of claim in field 10. Code Definition Blank Traditional/Indemnity M Managed Care S Coordination of Benefits T Managed Care w/Coordination of Benefits

Explanation of Benefits (EOB)

Fields 1 - 13

The EOB is provided to the BCBSTX subscriber and also to the provider when the subscriber is part of an ASO (Administrative Service Only) group.

The table below provides a key to this report. Field

Number

Field Name Information Provided 1 N/A The ASO Account name or the BCBSTX

logo.

2 Claim Received On The date the claim was received by BCBSTX.

3 N/A The date the claim was paid.

4 Subscriber The subscriber’s name will appear here. 5 Patient The patient’s name as reported to BCBSTX

on the claim submitted.

6 Subscriber ID The subscriber’s identification number from the ID card.

7 Group Number Number that identifies the subscriber’s group listed on the ID card.

8 Control Number A unique number assigned to each claim as it enters the BCBSTX claims processing system.

9 Dates of Service The beginning and ending dates of service indicated on the claim. If the claim contains a single date of service, the “To” column will be blank.

Explanation of Benefits (EOB),

Fields 14a – 14e

The following table explains field 14a-14e “Your Responsibility” or the patient’s share:

Field Number

Field Name Information Provided

14a Noncovered The amount for any services not covered by the subscriber’s benefit plan.

14b Copay Amount of payment the subscriber makes at the time services are provided, if indicated by the subscriber’s benefit plan.

14c Deductible The amount of eligible expenses that the subscriber is responsible for before benefits will be available.

14d Cost Share The portion of covered expenses the (Coinsurance) subscriber pays after the deductible has been satisfied.

14e Your Total This is the total amount the subscriber is responsible for based on the charges submitted. This total includes any amounts the subscriber may have previously paid to the provider.

Fields 15 - 16

The table below continues the EOB key:

15 Your Benefit The amount that is payable on the Plan Pays claim submitted to BCBSTX. This is the amount of payment issued to the BlueChoice Network provider.

16 Explanations An alpha code matching a narrative explanation listed at field 18.

Explanation of Benefits (EOB),

Fields 17 – 21

The table below completes the EOB key: Field

Number

Field Name Information Provided

17 Totals The totals of each of the following columns: • Charges Submitted • Eligible Charges • Noncovered • Copay • Deductible • Cost Share • Benefit Plan Pays

18 Explanations: This is a narrative describing claims processing.

19 N/A Deductible/Cost

Share/Year-to-Date/Maximum information will be listed here. This is a summary of subscriber liability for cost share and/or deductible, if applicable to this claim.

20 N/A Customer Service address and telephone numbers will be displayed here. Inquiries regarding claims processing would be handled at this address or telephone number. 21 N/A When payment is made, the check is attached