The Illinois Department of Healthcare and Family Services (HFS) has entered into a contract with Blue Cross and Blue Shield of Illinois (BCBSIL) to offer Blue Cross Community Health Plans (BCCHPSM) beginning Jan. 1, 2018. BCCHP will be offered to eligible participants in every county of Illinois. Blue Cross
Community Health Plans replaces three previous Medicaid programs: Enrollment in a managed care organization (MCO) is mandatory for those individuals who are eligible for Medicaid Managed Care. Eligible individuals may enroll in the plan of their
choice, or the State of Illinois will automatically enroll them. Illinois Client Enrollment Services (ICES) provides individuals with access to unbiased education and information on available health plan options and assists members in the enrollment processes. BCBSIL has a network of independently contracted providers including physicians, hospitals, skilled nursing facilities, ancillary providers, Long Term Supports and Services (LTSS) and other health care providers through which members
may obtain covered services. Required Training for Providers For links to our online training modules please refer to the
Medicare/Medicaid page in the Network Participation section of our website at
bcbsil.com/provider. For More Information A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association © Copyright Health Care Service Corporation. All Rights Reserved. File is in portable document format (PDF). To view this file, you may need to install a PDF reader program. Most PDF readers are a free download. One option is Adobe® Reader® which has a built-in reader. Other Adobe accessibility tools and information can be downloaded at http://access.adobe.com You are leaving this website/app (“site”). This new site may be offered by a vendor or an independent third party. The site may also contain non-Medicare related information. In addition, some sites may require you to agree to their terms of use and privacy policy. Federal Deficit Reduction Act (DRA) of 2015 and Fraud, Waste and AbuseHealth care organizations subject to Section 6032 of the federal Deficit Reduction Act of 2005 (the “DRA”) are required to educate their providers and contractors about the False Claims Act as well as the organization’s policies and programs for detecting and preventing fraud, waste and abuse. The following documents are intended to satisfy Highmark Blue Cross Blue Shield of Western New York’s obligations under the DRA. We know you share Blue Cross Blue Shield’s goal of ensuring that all clinical and business activities are conducted in full compliance with applicable laws and government program requirements. Accordingly, we look forward to your cooperation in applying Blue Cross Blue Shield’s fraud prevention and detection policies and programs in connection with the services you provide to our members. If you have any questions regarding these documents, please do not hesitate to contact Blue Cross Blue Shield’s fraud prevention program at 716-887-8451 or 1-800-333-8451.
Electronic Billing
Blue Cross Blue Shield contracts with Administrative Services of Kansas, Inc. (ASK) to be our vendor for this service. ASK will receive all provider claims submissions and will perform any necessary edits to ensure the claims meet all regulatory and contract requirements. The claims will then be transferred to the health plan for adjudication and payment. ASK was selected because of their experience and credibility in the Electronic Data Interface (EDI) marketplace. We have chosen this company to be our partner in achieving the electronic transaction component of HIPAA. Enrolling with ASKTo obtain information on or sign up for Electronic Claims Submission with ASK, please visit their website, located on the Internet at ask-edi.com. Click on “Getting Started” on the menu bar. Please fill out the online form completely to register and click ‘Submit’. If you would like to contact ASK by phone, please call their toll free number at 1-800-472-6481; press option 1 for New York Customers and select option 1 again to connect to an EDI Helpdesk specialist. Click the ‘Resource Center’ tab for:
Acceptable Claim FormatsASK accepts and edits electronic claims submissions using the following formats:
Providers receive a clearinghouse response report for each electronic submission that indicates:
Changes in Claims Routing ServicesMedicare Primary Claims Routing Please contact Medicare's Electronic Media Communications Department, at 1-607-766-6000, as soon as possible to set up your system for direct submission of these claims to Medicare. Other Payer Claims RoutingWhen you enroll with ASK, you will be offered a one-year free trial membership to ASK's commercial clearinghouse, EDI Midwest. This offer provides you with the option of clearing other payers' claims through ASK. EDI Midwest routes claims to 800 payers around the nation. EDI Midwest will only accept claims that can be sent to their final destination electronically. Your ASK EDI Account Representative can give you more detailed information about EDI Midwest at the time you enroll to submit your claims to ASK. You can contact ASK directly at 1-800-472-6481. If you elect not to use the services of EDI Midwest, please make arrangements with your current clearinghouse vendor or submitter to have non-Blue Cross Blue Shield claims submitted directly to the appropriate payer. We will continue to process claims destined for our vendors and all of our lines of business including: Non Direct-Bill ITS/BlueCard, Express Scripts, and Federal Employee Program (FEP). Non-Electronic Claim FormsNon-electronic claims should be submitted using the approved CMS-1500 or UB-04 claim form. Please note that all required fields of the claim form must be completed, or the claim may be returned for additional information. These forms can be purchased from your forms vendor National Provider Identifier (NPI)We require the submission of the provider's Billing NPI number and not the 12-digit provider number on the claim form. Mail all claims, (Local, Indemnity, and Managed Care, including Senior Blue HMO and BlueSaver plans), to: Highmark Blue Cross Blue Shield of Western New York Federal Employee Program (FEP): To improve accuracy and timeliness of paper claim submissions, we utilize Optical Character Recognition/Intelligent Character Recognition (OCR/ICR). To maximize the efficiency of this technology, we are asking providers who submit paper claims to use the red CMS 1500 (2-12) or UB-04 standard claim forms. Please note: Edits for electronic claims and paper claims are exactly the same. Submitting a paper claim that originally rejected electronically without fixing the problem will only lead to a rejection of the paper claim as well. All claims for Medicare covered services and items that are the result of physician’s order or referral shall include the ordering/referring physician’s name, NPI, and taxonomy code in boxes 17, 17a, and 17b of the CMS 1500 claim form. The following services/situations require the submission of the referring/ordering provider information. This is not an all-inclusive list:
|
ICD10 effective Oct. 1, 2015 |
Z00.6 (Encounter for examination for normal comparison and control in clinical research program. |
HCPCS
S9988 services provided as part of a phase I clinical trial
S9990 services provided as part of a phase II clinical trial
S9991 services provided as part of a phase III clinical trial
One of the above HCPCS codes must be included as a one-line entry on each claim with $0.00 indicated for the charge. These codes are informational and not separately reimbursed.
Modifiers
One of the following modifiers needs to be indicated on each clinical trial service:
Q0 -Investigational clinical service provided in an approved clinical research study.
The Q0 modifier is used for the item, device, drug or service that is under investigation in the clinical trial or for services unique to the trial requirements, such as data collection.
Q1 -Routine clinical service provided in an approved clinical research study.
Routine services related to qualifying clinical trials submitted with a modifier have potential for coverage. However, if the modifier indicating the routine service is a part of a qualifying trial (Q1) is not documented, the service will be considered investigational as part of a non-qualifying trial, and therefore not eligible for payment.
Use of these modifiers attests to the services being performed in qualifying clinical trials.
Condition code 30 - Available for inpatient claims to indicate the admission includes qualifying trial services.
It is expected that we will not be billed for any services related to non-qualifying trials or for anything provided free of charge by trial sponsors.