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BLUE CROSS AND BLUE SHIELD OF LOUISIANA

VIEWS: 488 PAGES: 53

									BLUE CROSS AND BLUE SHIELD OF
         LOUISIANA


   PROFESSIONAL 837P/1500

        ELECTRONIC
   BUSINESS RULES GUIDE
                                      BLUE CROSS BLUE SHIELD OF LOUISIANA
                             PROFESSIONAL 837P/1500 ELECTRONIC BUSINESS RULES GUIDE




                                Table of Contents
I. Introduction of Guide......................................................................................... 3
II. General Information .......................................................................................... 4
        Hours of Operation ..................................................................................... 4
        Customer Support ...................................................................................... 4
        Processing Cycle ....................................................................................... 4
III. Identifying Blue Cross Contract Numbers ........................................................ 5
IV. Professional Claims Business Rules ............................................................... 7
V. Claim Specialties ............................................................................................ 23
        Ambulance Claims ................................................................................... 23
        Unspecified Procedure Codes.................................................................. 23
        HCPCS 99070.......................................................................................... 23
        Nursing Services ...................................................................................... 24
        Anesthesia ............................................................................................... 24
VI. Reports Generated from Clearinghouse ........................................................ 26
        Communication Reports ........................................................................... 27
        Functional Acknowledgment Reports ....................................................... 29
        Claims Submission Validation Reports (Claims transactions only) .......... 32
VII. 835 Remit Process ....................................................................................... 42
VIII. Not Accepted Claims Error Report Codes ................................................... 43




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                                                December 9, 2009
                              BLUE CROSS BLUE SHIELD OF LOUISIANA
                     PROFESSIONAL 837P/1500 ELECTRONIC BUSINESS RULES GUIDE




I. Introduction of Guide
The information provided here offers specific details on BCBSLA professional 1500
claims completion. Please be aware that some of the instructions described within this
handbook may not apply to your location and that specialized services such as
anesthesia, durable medical equipment or ambulance are referenced in separate
sections. BCBSLA claims must also conform to the provisions set forth in the provider
network contracts.

This document was designed to provide technical staff with the criteria needed to
develop validation edits for BCBSLA Professional claims. Additionally, this guide
should also be used by office staff that is responsible for the daily submission,
confirmation and correction of BCBSLA claims.

If a transaction does not meet the minimal specifications outlined in this guide, then
BCBSLA may not be able to process those transactions. Claims that do not pass
the stated criteria are subject to rejection, deletion or a delay in processing. Refer
to the Claim Confirmation and Reporting section for additional details.

If you have questions about the information in this guide, please contact BCBSLA EDI
Services.

Phone:                        225-291-4EDI (4334)
Email Address:                edich@bcbsla.com

Mailing Address:              EDI Customer Operations
                              Attention: Clearinghouse Services
                              Blue Cross and Blue Shield of Louisiana
                              P.O. Box 98029
                              Baton Rouge, LA 70898-9029




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                            BLUE CROSS BLUE SHIELD OF LOUISIANA
                   PROFESSIONAL 837P/1500 ELECTRONIC BUSINESS RULES GUIDE




II. General Information
Hours of Operation
     The system will be available 24 hours, 7 days a week. The system will be
     periodically unavailable for scheduled maintenance and updates outside
     of normal business hours only. Though BCBSLA strives to have the
     systems available 24 hours, 7 days a week, uninterrupted service is not
     guaranteed.


Customer Support
     Customer support will be provided during our normal business hours:
     Monday – Friday*, 8:00 a.m. to 4:30 p.m. Central Standard Time (CST)

      *Except holidays

      Telephone Support 225-291-4EDI (4334)

      Email Address: edich@bcbsla.com


      Mailing Address:      EDI Customer Operations
                            Attention: Clearinghouse Services
                            Blue Cross and Blue Shield of Louisiana
                            P.O. Box 98029
                            Baton Rouge, LA 70898-9029


Processing Cycle
     BCBSLA will accept an unlimited number of transmissions within an
     operating day; however, batch transactions will be accumulated and
     processed once a day.


          Batch Transactions: Batch transmissions are moved at 3 p.m.
          (CST) for nightly processing. All batch transmissions received after
          this time will be processed the following business day.


          Real-Time Transactions: Real-time transactions will be processed
          while the Trading Partner is connected.




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                             BLUE CROSS BLUE SHIELD OF LOUISIANA
                    PROFESSIONAL 837P/1500 ELECTRONIC BUSINESS RULES GUIDE




III. Identifying Blue Cross Contract Numbers

Alpha prefixes
Blue Cross and Blue Shield plans assign an individual contract number to each
subscriber. The contract number uniquely identifies the specific contract.

Most contract numbers are preceded by a 3-position alpha prefix. The alpha
prefix identifies the Plan or national account to which the member belongs. The
alpha prefix is the key element used to identify and correctly route
electronic or hard copy claims to the appropriate processing area or Blue
Cross plan.


See the example of a BCBSLA card below. The member number and alpha
prefix are circled.




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                             BLUE CROSS BLUE SHIELD OF LOUISIANA
                    PROFESSIONAL 837P/1500 ELECTRONIC BUSINESS RULES GUIDE




Identifying Contracts
BCBSLA currently processes claims through our central operating system
Legacy, as well as our new updated claims system called Facets. Eventually, all
lines of business will be moved to the new Facets system. The information
below differentiates the contract numbers within the Legacy and Facets systems.

Legacy

Blue Cross and Blue Shield of Louisiana (BCBSLA) contracts:
      • Begin with alpha prefix “XU?”
      • Followed by 8 to 10 positions
      • If the contract has 8 positions, the 7th position can be numeric or alpha
         (if alpha will be A, B, N, V or X) last position will be 1.
      • If the contract number has 9 positions the 10th position will be 1-9 or C.
      • Example: XUA 1234567891 or XUB 123456A1

Federal Employees Contracts (FEP)
         • FEP contracts do not have an alpha prefix
         • The first position of the contract number must be an 'R', the second
           thru ninth will be numeric and the tenth position, if present, will be
           zero (0).

Facets
      •   Begins with alpha prefix “XU”
      •   Contract number begins with a 200 behind the alpha prefix

Out-of-area and National account prefixes
      • Begin with any alpha prefix other than XU
      • Can be any length of characters
      • Example: MBN 123456789




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                                         PROFESSIONAL 837P/1500 ELECTRONIC BUSINESS RULES GUIDE




IV. Professional Claims Business Rules
BCBSLA will accept all valid 837 transactions, but the table below depicts the data elements that will facilitate accurate
and prompt claims processing for professional claims.


1500       Field Name        320 NSF      837P Reference and Page                 Notes
Form                                      Number
    1      Type(s) of                                                             Not used by BCBSLA
           Health
           Insurance
   1a      Insured’s I.D.    DA0: 18.0         2010BA/NM109 p 119                 •  Enter the subscriber’s identification number
           Number                              2010CA/NM109 p 159                    exactly as it appears on the identification
                                                2330A/NM109 p 352                    card including the 3-position alpha prefix.
                                                                                  • All BCBSLA contract numbers will be a total
                                                                                     of 11 or 13 positions (including the 3
                                                                                     position alpha prefix).
                                                                                  • When prefix is present, first two positions
                                                                                     must be XU.
                                                                                  • Third position will be alpha (A-Z).
                                                                                  • Remaining member number will be 8 or 10
                                                                                     positions
                                                                                  • If the contract has 8 positions, the 7th
                                                                                     position can be numeric or alpha (If alpha
                                                                                     will be A, B, N, V or X and the last position
                                                                                     must be 1).
                                                                                  • If the contract number has 10 positions, the
                                                                                     first nine will be numeric and the 10th
                                                                                     position can be 1-9 or C.
                                                                                  Example: XUL1234567891 XUB123456X1



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                                  PROFESSIONAL 837P/1500 ELECTRONIC BUSINESS RULES GUIDE




Professional Claims Business Rules, continued
1500   Field Name       320 NSF    837P Reference and Page                 Notes
Form                               Number
                                                                           Out-of-Area contracts (also known as Blue
                                                                           Card, ITS, out-of-state National, NASCO).
                                                                           These contracts will begin with an alpha prefix
                                                                           other than XU. A valid three position alpha
                                                                           prefix must be present.
                                                                           EXAMPLE: YAA1234567890

                                                                           Federal contracts:
                                                                           If contract is federal, the 1ST position must be
                                                                           ‘R.’
                                                                           The 2ND thru 9TH positions must be numeric.
                                                                           If a tenth, position must be (zero) 0.
                                                                           EXAMPLE: R034567810

  2    Patient’s Last   CA0:4.0         2010BA/NM103 p 118                 •    Must be the last name of the patient
       Name                             2010CA/NM103 p 158                      receiving services. If the patient is a
                                                                                stepchild or grandchild, indicate last name
                                                                                even if it differs from the policyholder’s
                                                                                name on the ID card.
                                                                           •    Must have an alphabetic character in the 1st
                                                                                and 2nd positions.
                                                                           •    Do not use spaces, punctuation or titles.




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                                    PROFESSIONAL 837P/1500 ELECTRONIC BUSINESS RULES GUIDE




Professional Claims Business Rules, continued
1500   Field Name        320 NSF     837P Reference and Page                 Notes
Form                                 Number
       Patient’s First   CA0: 5.0         2010BA/NM104 p 118                 •    The first position of the field cannot be
       Name                               2010CA/NM104 p 158                      blank and must be alpha. The remaining
                                                                                  positions should be alpha or blank.
                                                                             •    When filing for a newborn, the infant’s given
                                                                                  name must be used.
                                                                             •    Patient’s first name cannot be BABY,
                                                                                  BABYBOY, BABYBOY1, BABYBOY2,
                                                                                  BABYBOY2, BABYBOY3, BABYBOY4,
                                                                                  BABYGIRL, BABYGIRL1, BABYGIRL2,
                                                                                  BABYGIRL3, BABYGIRL4, BABY1,
                                                                                  BABY2, BABY3, BABY4, GIRL, BOY,
                                                                                  BOY1, BOY2, BOY3, BOY4, GIRL1,
                                                                                  GIRL2, GIRL3, GIRL4, INFANT, TWIN,
                                                                                  NEWBORN, NEWBO, INFANT1, INFANT2,
                                                                                  INFANT3, INFANT4, BABY BOY1, BABY
                                                                                  BOY2, BABY BOY3, BABY BOY4, BABY
                                                                                  GIRL1, BABY GIRL2, BABY GIRL3, BABY
                                                                                  GIRL4, BAB1, BAB2, BAB3, BAB4,
                                                                                  UNKNOWN, or TRIPLET.

       Patient’s         CA0: 6.0         2010BA/NM105 p 118                 •    Can be middle initial of patient receiving
       Middle Initial                     2010CA/NM105 p 158                      services. If present, must be alpha.




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                                     PROFESSIONAL 837P/1500 ELECTRONIC BUSINESS RULES GUIDE




Professional Claims Business Rules, continued
1500   Field Name        320 NSF      837P Reference and Page                 Notes
Form                                  Number
  3    Patient’s Birth   CA0: 8.0          2010BA/DMG02 p 125                 •    Must be the month, day and year that
       Date                                2010CA/DMG02 p 165                      patient was born.
                                                                              •    Birth date must be prior to or equal to the
                                                                                   first date of service for the charges being
                                                                                   submitted.
       Patient’s Sex     CA0: 9.0          2010BA/DMG03 p 125                 •    Must be the code indicating the patient’s
                                           2010CA/DMG03 p 165                      sex.
                                                                              •    F, M and U are valid codes; however, in
                                                                                   order for BCBSLA to complete processing,
                                                                                   F or M must be reported.
  4    Insured’s Last    DA0: 19.0         2010BA/NM103 p 118                 •    Must be the member’s /policyholder’s last
       Name                                 2330A/NM103 p 351                      name as indicated on the identification
                                                                                   card.

       Insured’s First   DA0: 20.0         2010BA/NM104 p 118                 •    Must be the member’s/policyholder’s first
       Name                                 2330A/NM104 p 351                      name as indicated on the identification
                                                                                   card.

       Insured’s         DA0: 21.0         2010BA/NM105 p 118                 •    Can be the member’s/policyholder’s middle
       Middle Initial                       2330A/NM105 p 351                      initial.




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Professional Claims Business Rules, continued
1500   Field Name        320 NSF        837P Reference and Page                 Notes
Form                                    Number
   5   Patient’s         CA0: 11.0 -          2010BA/N301 p 121                 •    Can be the patient’s current street number and
       Address (No.      12.0                 2010CA/N301 p 161                      street name.
       Street)
                                              2010BA| N302 p 121
                                              2010CA/N302 p 161

       Patient’s City,   CA0: 13              2010BA /N401 p 122                •    Can be patient’s city.
                                              2010CA/N401 p 162

       Patient’s State   CA0: 14.0            2010BA /N402 p 123                •    Can be patient’s state.
                                              2010CA/N402 p 162

       Patient’s Zip     CA0: 15              2010BA /N403 p 123                •    Can be patient’s ZIP.
       Code                                   2010CA/N403 p 162

       Patient’s         CA0: 16                                                •    Not used by BCBSLA.
       Phone
   6   Patient’s         DA0: 17.0            2000B/SBR02 p 111                 •    Must indicate the relationship of the patient to the
       Relationship                           2000C/PAT01 p 154                      policyholder.
       to Insured                              2320/SBR02 p 319




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   Professional Claims Business Rules, continued
1500 Form   Field Name        320 NSF        837P Reference and Page                 Notes
                                             Number
    7       Insured’s         DA2: 4.0 –           2010BA/N301 p 121                 •    Can be the members/policyholder’s address and
            Address           5.0                   2330A/N301 p 354                      street.
            (No., Street)
                                                   2010BA/N302 p 121
                                                    2330A/N302 p 354

            Insured’s City    DA2: 6.0             2010BA/N401 p 122                 •    Can be the member’s/policyholder’s city.
                                                    2330A/N401 p 355                 •    Must be present for ITS contracts.

            Insured’s State   DA2: 7.0             2010BA/N402 p 123                 •    Can be the member’s/policyholder’s state.
                                                    2330A/N402 p 356                 •    Must be present for ITS contracts.

            Insured’s ZIP     DA2: 8.0             2010BA/N403 p 123                 •    Can be the member’s/policyholder’s ZIP code.
            Code                                    2330A/N403 p 356                 •    Must be present for ITS contracts.

            Insured’s         DA2: 9.0                                               •    Not used by BCBSLA
            Telephone
    8       Patient Status    CA0: 17.0                      N/A                     •    Not used by BCBSLA
                              18.0

    9       Other             DA0: 19.0 –        2330A/NM103, 104, 105               •    If the patient has other health insurance, enter the
            Insured’s         20.0, 21.0                p 351                             name of the member/policyholder.
            Name
    9a      Other             DAO: 18              2330A/NM109 p 352                 •    If the patient has other health insurance, enter the
            Insured’s                                                                     member/policy number.
            Policy or
            Group Number




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Professional Claims Business Rules, continued
1500   Field Name       320 NSF     837P Reference and Page                 Notes
Form                                Number
  9b   Other            DAO: 24                                             •    If the patient has other health insurance, enter the
       Insured’s Date                      2320/DMG02 p 343                      other member/policyholder’s date of birth and sex.
       of Birth
       Sex
  9c   Employer’s
       Name or                                                              •    Not used by BCBSLA
       School Name
  9d   Insurance Plan                     2330B/NM103 p 360                 •    If the patient has other coverage, must be the
       Name or                                                                   name of the other insurance,
       Program Name
  10   Is patient’s                                                         •    Indicates whether the patient’s condition is a result
       condition                                                                 of employment (current or previous), auto
       related to:                                                               accident, or other accident.
       a.                                 2300/CLM11 - 1 thru               •    Must be supplied if a diagnosis code within the
       Employment?                             CLM11 - 3                         following range is present:
                        EA0: 4.0                 p 176                                • 800 through 995.9 (excluding 995.3)
       b. Auto                                                                        • V15.5, V15.6, V15.85, V71.3, V71.4,
       Accident?        EA0: 5.0
                                                                                            V71.5V71.6
       c. Other
       Accident?                                                                     •      525.11, 692.71,692.76, 692.77 , 692.82
                                                                                            733.93 to 733.95 and 733.10 to 733.19




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Professional Claims Business Rules, continued
1500    Field Name       320 NSF      837P Reference and Page                 Notes
Form                                  Number
  11    Insured’s        DA0: 10            2000B/SBR03 p 111                 •    BCBSLA does not require group number for
        Policy Group                                                               processing. However, if submitting claims in an
                                                                                   837P format, SBR03 (group number) or SBR04
                                                                                   (group name) must be present in order to achieve
                                                                                   HIPAA compliance. If unavailable, “None” can be
                                                                                   submitted in SBR04 to achieve HIPAA
                                                                                   compliancy.

  11a   Insured’s Date   DA0: 24.0         2010BA/DMG02 p 125                 •    If the patient’s relationship to insured is anything
        of Birth                                                                   other than “Self,” the insured date of birth and
        Sex                                                                        gender must be present.
 11b    Employer’s                                                            •    Not used by BCBSLA
        Name or
        School Name
  11c   Insurance plan   DAO: 09           2010BB/NM103 p 131                 •    Not used by BCBSLA
        name or
        program name
 11d    Is There         CA0: 22.0           2320 & 2330 Loop                 •    If the patient has other health insurance coverage,
        Another Health                                                             the 2320 and 2330 loop of the 837P must be
        Benefit Plan?                                                              present and contain all applicable data.

  12    Patient’s or     EA0: 13.0           2300/CLM09 p 175                 •    This field must indicate whether the provider has
        Authorized                                                                 on file a signed statement by the patient
        Person’s                                                                   authorizing the release of medical data.
        Signature




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    Professional Claims Business Rules, continued
1500 Form   Field Name         320 NSF      837P Reference and Page                 Notes
                                            Number
     13     Insured’s or       DA0: 15.0           2300/CLM08 p 175                 •     Benefits Assignment indicator. Indicate one of the
            Authorized                                                                    following codes that indicates who will receive the
            Person’s                                                                      assignment of benefits:
            Signature                                                                     ‘Y’ – Payment to provider
                                                                                          ‘N’ – Payment to subscriber

     14     Date Of            EA0: 7.0            2300/DTP03 p 189                 •     Must indicate a date of accident when a diagnosis
            Current                                2300/DTP03 p 196                       code is in the following range:
            Illness, Injury,                       2400/DTP03 p 453
            Pregnancy                              2300/DTP03 p 195                     - 800 through 995.9 (excluding 995.3)
                                                                                        - V15.5, V15.6, V15.85, V71.3, V71.4, V71.5, V71.6
                                                                                        - 525.11
                                                                                        - 692.71
                                                                                        - 692.76
                                                                                        - 692.77
                                                                                        - 692.82
                                                                                        - 733.93 to 733.95
                                                                                        - 733.10 to 733.19

                                                                                    •     HIPAA requires that the last menstrual period
                                                                                          (LMP) date be present when claim is pregnancy
                                                                                          related.




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Professional Claims Business Rules, continued
1500    Field Name        320 NSF        837P Reference and Page                 Notes
Form                                     Number
  15    If Patient Has    EA0: 15.0                                              •    Not used by BCBSLA
        Had Same or       16.0
        Similar Illness
  16    Dates Patient     EA0: 18.0             2300/DTP03 p 202                 •    Disability Begin: If claim involves disability, where
        Unable To         19.0                  2300/DTP03 p 204                      in the opinion of the provider, the patient was or
        Work In                                                                       will be unable to perform the duties normally
        Current                                                                       associated with his/her work, enter the dates when
        Occupation                                                                    applicable.
  17    Name of           EA0: 24.0 –          2310A/NM103 p 283                 •    Can be the referring physician’s complete name if
        Referring         26.0                 2310A/NM104 p 283                      applicable.
        Physician                              2310A/NM105 p 284
  17a   ID Number of      EAO: 20              2310A/REF02 p 289                 •    Can be the referring physician’s BCBSLA provider
        Referring                                                                     number if applicable.
        Physician
  18    Hospitalization   EA0: 28.0 &     Admit: 2300/DTP03 p 209                •    Enter dates of admission to and discharge from
        Dates Related     29.0           Discharge Date: 2300/DTP03                   hospital if applicable.
        To Current                                 p 211
        Services
  19                                                                             •    N/A
  20    Outside Lab       EAO: 30.0                                              •    Not used by BCBSLA




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Professional Claims Business Rules, continued
1500   Field Name      320 NSF      837P Reference and Page                 Notes
Form                                Number
  21   Diagnosis or    EA0:                 2300/HI01/ p 266                •    The 837P allows up to 8 ICD-9 diagnosis codes.
       Nature of       32.0                 2300/HI02 p 266                      The BCBSLA adjudication system will recognize
       Illness or      33.0                 2300/HI03 p 267                      the first 4 diagnosis codes reported.
       Injury          34.0                 2300/HI04 p 268                 •    At least one valid diagnosis code must be present.
                       35.0                                                 •    The diagnosis code fields must have E, V, or a
                                                                                 numeric character in the first position, with
                                                                                 numeric characters in the second and third. The
                                                                                 fourth & fifth positions must be numeric or blank.

  22   Medicaid                                                             •    Not used by BCBSLA
       Resubmission
       Code
  23   Prior           DA0: 14.0           2300/REF02 p 228                 •    Can be the BCBSLA referral or pre-certification
       Authorization                                                             authorization number obtained from
                                                                                 BCBSLA/HMOLA, if applicable.

  24                                                                        •    NOTES: No duplicate charges can be submitted.
 A-K                                                                             The line item is a duplicate if the date of service,
                                                                                 place of service, modifier, charge, and performing
                                                                                 provider are the same as a previous line item.




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Professional Claims Business Rules, continued
1500    Field Name   320 NSF       837P Reference and Page                 Notes
Form                               Number
 24 A   Date(s) of   FA0: 5.0 –           2400/DTP03 p 436                 •   Must be the FROM and TO dates of service for
        Service      6.0                                                       the charges being billed.
        From To                                                            • Date must be on or before the current date.
                                                                           • The FROM date must be prior to or the same as
                                                                               the TO date.
                                                                           • The TO date must be after or the same as the
                                                                               FROM date.
                                                                           • TO/FROM dates CANNOT overlap calendar
                                                                               months, except when the place of treatment is 21
                                                                               (inpatient). Dates on all line items must be in the
                                                                               same calendar year.
                                                                           • Charges for different years must be submitted on
                                                                               sep claims
 24 B   Place of     FA0: 7.0             2300/CLM05 p 172                 • Must be the code that identifies where the service
        Service                           2400/SV105 p 404                     was performed.
                                                                           • The place of service must be compatible with the
                                                                               CPT code as indicated below:
                                                                           CPT CODE                PLACE OF SERVICE
                                                                           99201-99220             11, 22, 23, 62, 65, 71, 72, or 81
                                                                           99221-99238             21, 25, 31, 51, 52, 55, 56, or 61
                                                                           99241-99245           11, 12, 22, 23, 24, 32, 33, 62,
                                                                           65, 71, 72, or 81
                                                                           99251-99263             21, 25, 31, 51, 52, 55, 56, or 61
                                                                           99281-99285             22, 23
                                                                           99301-99333             31, 32
                                                                           99341-99353             12




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Professional Claims Business Rules, continued
1500    Field Name     320 NSF      837P Reference and Page                 Notes
Form                                Number
 24 C   Type of        FA0 8.0                      N/A                     •    N/A
        Service
 24 D   Procedures,    FA0: 9.0       2400/SV101/C003-02 p 401              •    Must be the appropriate CPT4 or HCPCS code
        Services, or                                                             that describes the service rendered.
        Supplies                                                            •    Must be a valid and current code.
        CPT/HCPCS
        Modifier       FA0: 10.0      2400/SV101/C003-03 p 401              •    Identifies special circumstances related to the
                                                                                 service. Append modifiers to the CPT and
                                                                                 HCPCS codes, when appropriate.
                                                                            •    Must be a valid modifier for the CPT code as listed
                                                                                 in the CPT manual. The modifier must be
                                                                                 compatible with the CPT according to the
                                                                                 guidelines listed below:

                                                                            CPT Range Valid Modifier
                                                                                 10000-69999 20, 22, 26, 32, 50, 51, 52, 54,
                                                                                 55, 56, 62, 66, 75, 76, 77, 78, 79, 80, 81, or 82
                                                                                 70000-79999             22, 26, 32, 51, 52, 62,
                                                                                 66, 75, 76, 77, 78, 79, 80, 81, or 82
                                                                                 80000-89999             22, 26, 32, 52, or 90
                                                                                 90000-99100             22, 26, 32, 51, 52, 55,
                                                                                 56, 75, 76, 77, 78, or 79
                                                                                 99201-99353             21, 24, 25, 32, 52, 78, or
                                                                                 79




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                                     PROFESSIONAL 837P/1500 ELECTRONIC BUSINESS RULES GUIDE




Professional Claims Business Rules, continued
1500    Field Name       320 NSF      837P Reference and Page                 Notes
Form                                  Number
 24 E   Diagnosis        FA0:           2400/SV107-01 – 04 p 405              •    A pointer to the diagnosis code in the order of
        Code             14.0                                                      importance for this service.
                         -17.0                                                •    Must be the numeric code that corresponds with
                                                                                   the diagnosis code listed in the diagnosis field.

 24 F   Charges          FA0:                2400/SV102 p 402                 •    Must be the total charge for each service
                         13.0                                                      rendered. Providers should bill their usual charge
                                                                                   to BCBSLA regardless of our allowable charges.

 24 G   Days or Units    FA0                 2400/SV104 p 403                 •    Must be the number of days or units that service
                         18.0                                                      was rendered, unless the CPT/HCPCS code
                                                                                   description accounts for multiple units.
                                                                              •    If charges are for anesthesia services, this field
                                                                                   must indicate the NUMBER OF MINUTES the
                                                                                   anesthesia was administered

 24 H                                                                         •    For BCBSLA office use only.
 24 I                                                                         •    For BCBSLA office use only.
 24 J                                                                         •    For BCBSLA office use only.
 24 K   PROVNUM          BA0: 14.0          2310B REF02 p 297                 •    Must be the physician’s NPI number OR provider
                                             2420 REF02 p 508                      number assigned by BCBSLA for the
                                                                                   physician/clinic who rendered services.
  25    Federal Tax ID   BA0: 6.0           2010AA NM109 p 86                 •    Must be the provider’s/clinic’s Federal Tax
        Number                                                                     Identification number used for Internal Revenue
                                                                                   Service payment reporting purposes




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                                  PROFESSIONAL 837P/1500 ELECTRONIC BUSINESS RULES GUIDE




Professional Claims Business Rules, continued
1500   Field Name     320 NSF      837P Reference and Page                 Notes
Form                               Number
  26   Patient’s      CA0: 3.0            2300/CLM01 p 171                 •    Can be the patient account number as assigned
       Account No.                                                              by the provider of services for identification
                                                                                purposes.
                                                                           •    A maximum of 15 positions will be returned on the
                                                                                paper payment register.
                                                                           •    A maximum of 20 positions will be stored and
                                                                                returned by BCBSLA on the 835 ERA.

  27   Accept                                                              •    Not used by BCBSLA.
       Assignment
  28   Total Charge   XA0: 12.0           2300/CLM02 p 172                 •    Must be the total of all line item charges on the
                                                                                claim.
                                                                           •    The maximum dollar amount BCBSLA can
                                                                                process is $99,999.99. Claims in excess of this
                                                                                amount may be rejected and should be filed hard
                                                                                copy.

  29   Amount Paid                                                         •    Not used by BCBSLA
  30   Balance Due                                                         •    Not used by BCBSLA
  31   Signature                                                           •    N/A
  32   Name and       EA0: 39.0            2310D NM1 p 304                 •    Provide information, if services were rendered at a
       Address of     EA1: 06 -             2310D N3 p 307                      facility other than the physician’s office or patient’s
       Facility       10                    2310D N4 p 308                      home.




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                                   PROFESSIONAL 837P/1500 ELECTRONIC BUSINESS RULES GUIDE




Professional Claims Business Rules, continued
1500   Field Name      320 NSF      837P Reference and Page                 Notes
Form                                Number
  33   Physician’s,    BA0: 14.0         2010AA REF02 p 92                  •    Enter the NPI number or BCBSLA provider
       Supplier’s      BA0: 18 –      2010AA NM103 – 104 p 85                    number assigned to the facility; Emergency Room
       Billing Name,   20             2010AA N3 – N4 p 88 - 89                   Physicians, physician, or physician group, which
       Address, ZIP    BA1: 13 -                                                 will receive reimbursement for the services billed.
       Code,           17                                                   •    Include the name and address of the billing
       Telephone                                                                 provider.
       Number                                                               •    Your unique BCBSLA assigned provider
                                                                                 number or NPI number is essential for claims
                                                                                 processing. This number must be indicated in
                                                                                 Loop 2010AA REF02.




                                                            22
                                                    December 9, 2009
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                                BUSINESS RULES FOR PROFESSIONAL CLAIMS




V. Claim Specialties
Ambulance Claims

For all contract types
       •   Ambulance services for all contract types (Regular, FEP, out-of-state, and
           NASCO) must be submitted in a professional format (837P)
       •   Mileage transported must be present as follows:

Loop       Element       Page #     Notes
2300       CR105         250        CR105 = DH
           CR106                    CR106 = Number of miles transported


For Federal and NASCO contracts only
       •   FEP contracts require modifiers to determine origin and destination of
           transportation as follows:

Loop       Element      Page #      Notes
2400       SV101 – 3, 4 401         Indicate origin and destination modifiers.

Unspecified Procedure Codes
Unspecified CPT4 and HCPCS codes usually end in “99.” Unspecified codes should be
used only if a more specific code is not available. Claims submitted with unspecified codes
will be accepted, but may encounter delays in processing.

HCPCS 99070
Claims submitted with HCPCS 99070 must indicate the exact name of the supply as
follows:

Loop       Element       Page #     Notes
2300       NTE01         247        NTE01 = ADD
2300       NTE02         247        NTE02 = name of supply




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                                BUSINESS RULES FOR PROFESSIONAL CLAIMS


Nursing Services
When billing nurse’s services, the claim must include the nurse’s license number (unless
Nursing Agency is billing for the services), nurse’s title and shifts worked. Indicate nurse’s
information as follows:

Loop     Element         Page #     Notes
2300     NTE01           247        NTE01 = ADD
2300     NTE02           247        NTE02 = nurses license number, title, and shifts
                                    worked

Anesthesia
To ensure proper processing when billing for anesthesia services, providers should
observe the following guidelines:

CPT Codes
Anesthesia services billed by anesthesiologists or CRNA’s must be filed using the
appropriate anesthesia CPT code (beginning with “0”). Exceptions to this rule are included
on the following page. Anesthesia services billed by physicians whose specialty is not
anesthesiology may continue to be billed under the appropriate surgery CPT with the
appropriate minutes, modifiers, and qualifying circumstances, if applicable.

Minutes of Administrations
Minutes of anesthesia administration must be indicated as follows:

Loop     Element         Page #     Notes
2400     SV104           403

Modifiers
CPT anesthesia codes (00100-01999) should be billed with one of the appropriate
modifiers:

AA, AD, GC, G8, G9, QK, QS, QX, QY, QZ, 23

Physical Status Modifiers
If physical status modifiers are applicable, the modifier must be one of the following:

P1, P2, P3, P4, P5, P6

Qualifying Circumstances
Qualifying circumstances are those factors that affect the anesthesia services and are
always billed in conjunction with anesthesia. The following procedures must be present if
applicable and cannot be reported alone and separate from anesthesia services:

99100         99116         99135           99140


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                                BUSINESS RULES FOR PROFESSIONAL CLAIMS




Anesthesia Billing Guidelines-Anesthesia Procedures Listing

     CPT        CPT             CPT                 CPT                  CPT
20526           62362           64520               94656                99222
20550           62365           64530               94657                99223
20551           62367           64550               94660                99231
20552           62368           64600               94662                99232
20553           63650           64605               94680                99233
20600           63660           64610               94681                99238
20605           63685           64620               94690                99239
20610           63688           64622               94750                99241
27096           64400           64623               94770                99242
31500           64402           64626               94799                99243
36400           64405           64627               95925                99244
36410           64408           64630               95926                99245
36420           64410           64640               95927                99251
36425           64412           64680               95955                99252
36488           64413           72275               95970                99253
36489           64415           73542               95971                99254
36490           64417           76005               99100                99255
36491           64418           92950               99116                99261
36600           64420           93312               99135                99262
36620           64421           93313               99140                99263
36625           64425           93314               99183                99271
36660           64430           93315               99190                99272
62263           64435           93316               99191                99255
62270           64445           93317               99192                99273
62273           64450           93318               99199                99274
62280           64470           93503               99201                99275
62281           64472           94010               99202                99291
62282           64475           94060               99203                99292
62310           64476           94150               99204                99440
62311           64479           94375               99205
62318           64480           94400               99211
62319           64483           94450               99212
62350           64484           94640               99213
62355           64505           94650               99214
62360           64508           94651               99215
62361           64510           94652               99221




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VI. Reports Generated from Clearinghouse
The BCBSLA Clearinghouse provides a series of reports to assist in the tracking and
monitoring of transactions. Clearinghouse reports are a critical part of the electronic
submission process.

The Trading Partner is responsible for monitoring all reports to ensure that all transactions
were received and accepted for processing by BCBSLA. In addition, the Trading Partner is
required to take corrective action when necessary. All questions regarding reports should
be directed to EDI Customer Operations at: 225-291- 4EDI (4334) or email
edich@bcbsla.com

We recommend that you maintain a copy of these reports for at least 60 days.


Summary of Reports Generated from Clearinghouse:

   1. Communication Reports
        a. TA1 Interchange Acknowledgement (all X12 transactions)

   2. Functional Acknowledgement Report
         a. 997 (all X12 transactions)
         b. BCCLREDI X12 Error Report (only for X12 transactions with errors)

   3. Claims Submission Validation Reports
         a. Accepted/Not Accepted (for all Claims transactions only)
         b. Accepted/Not Accepted (for all Facets claims transactions only)

   4. Activity Log
              The Activity Log is available from the submitter’s mailbox. The log lists
              files/reports that were sent and received Each listing provides the file/report
              name, date and time of the transmission, protocol used and the size of the
              file. See Exhibit M for an example of an Activity Log.

 5. BCTPERR Report
         This report is generated anytime the submitter ID within the transaction does
         not match the mailbox, or the Test/Production indicator does not match the
         file, or the claim filing indicator is not equal to BL, or the CLM segments within
         one ST-SE exceeds 5000. See Exhibit N for an example of a BCTPERR
         Report.

 6. DIR
             This command is used as a directory to view all activity in the trading
             partner’s mailbox.

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Communication Reports
Communication Reports are an immediate acknowledgement of successful communication
and receipt of transmitted files. They are the first step in the reconciliation process. They
are not an indication that the transmitted files were accepted for processing. The Trading
Partner is responsible for monitoring the reports and ensuring that all transactions
submitted were received by the BCBSLA Clearinghouse.

If you do not receive a communication report, we did not receive the transmission and the
transmission will need to be resent. You may refer to the Activity Log that is available from
your mailbox to review the status of previous submissions.


TA1 Interchange Acknowledgement
The TA1 provides the status of an X12 interchange header and trailer. Positive TA1
acknowledgements will not be utilized by BCBSLA. Trading Partners will automatically
receive a negative TA1 for files that cannot be processed or submitted for HIPAA
validation. See Exhibit A on the following page for an example of a negative TA1.




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                                         December 9, 2009
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                              BUSINESS RULES FOR PROFESSIONAL CLAIMS




Example of TA1 Interchange Acknowledgement Report (all X12 transactions)


Exhibit A: Negative (Rejected) TA1 Report

ISA*00*   *00*   *ZZ*BCBSLA001 *ZZ*T0001098         *090625*1320*U*00401*000000067*0*T*:~
TA1*000019998*090602*0913*R*009~
IEA*0*000000067~




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Functional Acknowledgment Reports

997
The 997 report is available for all X12 transactions and indicates the validity of a standard
transaction. Trading Partners will be able to pull this report the next time they connect to
the BCBSLA Clearinghouse. If the 997 contains a rejected status, in many cases the
trading partner will receive a BCCLREDI X12 Error Report (see below) with detailed error
descriptions. However, a 997 that rejected due to errors in the "Control Structure", or a
duplicate file received, will only create the 997 Reject. A BCCLREDI X12 Error Report
WILL NOT be generated on this X12 transaction with Control Structure errors. A duplicate
file is identified by the number received in the BHT03 segment.

On rejected 997’s the trading partner must make the corrections and retransmit the file.
See Exhibits D and E for examples of accepted and rejected 997 reports.

BCCLREDI X12 Error Report
The X12 Error Report indicates the validity of files submitted in the 837 format. Files that
do not meet standard HIPAA compliancy will be rejected. The report will include the data
contained in your file as well as specific error information. If further assistance is needed
with viewing this report, please contact our EDI Clearinghouse Support line at 225-291-
4334.

NOTE:
All reports will be named #########.DAT, where ######## is a sequential, unique
number. The BCCLREDI will need to be renamed from a .DAT to .HTML to view the X12
errors properly in internet explorer.

When an 837 file fails HIPAA validation, the entire file has failed and the trading partner will
receive a Claredi Report. This report is in an .html format. In order to correct the errors and
resubmit the file for payment, you must do the following:

   •   Copy and paste the Claredi report into a word document
   •   Click Control F, and do a find on all H1 and H2 errors within the Claredi file. These
       errors will be highlighted in RED in the file
   •   H1 and H2 errors are for syntax and format, and are the only two types of errors that
       BCBSLA uses to validate HIPAA validation.
   •   Correct any H1 or H2 errors within the 837 file, and resubmit the file to BCBSLA


See Exhibit F for an example of the X12 report.




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                                         December 9, 2009
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Examples of the 997 Functional Acknowledgement Reports

Exhibit D: Accepted 997 Acknowledgement

ISA*00* *00* *ZZ*BCBSLA001 *ZZ*T0001098 *090618*0844*U*00401*000000049*0*T*:~
GS*FA*BCBSLA001*T0001098*20090618*0844*24*X*004010X096A1~
ST*997*0001~
AK1*HC*17999~
AK2*837*00017999~
AK5*A~
AK9*A*1*1*1~
SE*6*0001~
GE*1*24~
IEA*1*000000049~.




Exhibit E: Rejected 997 Acknowledgement

ISA*00*   *00* *ZZ*BCBSLA001   *ZZ*T0001098 *090603*1527*U*00401*000000007*0*T*:~
GS*FA*BCBSLA001*T0001098*20090603*1527*4*X*004010X096A1~
ST*997*0001~
AK1*HC*17557~
AK2*837*00017557~
AK3*SV2*2527*2400*8~
AK4*3*782*6~
AK5*R*5~
AK9*R*1*1*0~
SE*8*0001~
GE*1*4~
IEA*1*000000007~




NOTE: If the 997 contains a rejected status, in many cases the trading partner will receive
a BCCLREDI X12 Error Report with detailed error descriptions. However, a 997 that
rejected due to errors in the "Control Structure", or a duplicate file received, will only create
the 997 Reject. A duplicate file is represented by the absence of the AK3 and AK4 segment
and when the AK9 05 field being blank. An X12 Error Report WILL NOT be generated on
this X12 transaction. A duplicate file is identified by the number received in the BHT03
segment.



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                                 BUSINESS RULES FOR PROFESSIONAL CLAIMS


Exhibit F: Example of the BCCLREDI X12 Error Report for a Professional Claim. Blue
Cross Validates on level one and two errors only. Levels are identified by H1-H6 in
the error section. Items below highlighted in Blue indicate the level.
ISA*00*1234567890*00*1234567890*ZZ*T0000000 *ZZ*BCBSLA001 *090601*1907*U*00401*000000032*0*T*:
GS*HC*T0000000*BCBSLA001*20090601*1907*1*X*004010X098A1
ST*837*0001
BHT*0019*00*0001*20090601*1907*CH
REF*87*004010X098A1
NM1*41*2*DERMATOLOGY SERVICES*****46*T00000
PER*IC*DOE DAVID*TE*3181111111
NM1*40*2*BLUE CROSS BLUE SHIELD*****46*53120
HL*1**20*1
NM1*85*2*DERMATOLOGY SERVICES*****24*712345678
[H 2010AA NM1 (null) 10 0 0 root.L_ISA.L_GS.837P.2000A.2010AA.NM1 N3 H20205 Incomplete loop (2010AA).
Missing mandatory N3 (Billing Provider Address).]
[H 2010AA NM1 (null) 10 0 0 root.L_ISA.L_GS.837P.2000A.2010AA.NM1 N4 H20205 Incomplete loop (2010AA).
Missing mandatory N4 (Billing Provider City/State/ZIP Code).]
 N3*ALLERGY SPECIALTY*3 CENTRAL CIRCLE
[H (null) N3 (null) 12 0 0 (null) N3 H10023 Unexpected segment (N3)]
N4*BATON ROUGE *LA*71201
[H (null) N4 (null) 13 0 0 (null) N4 H10023 Unexpected segment (N4)]
REF*1A*4111111111
[H 837P REF (null) 14 0 0 REF[1] (null) H10100 Segment (REF) occurs out of order]
 HL*2*1*22*0
SBR*P*18*77027/000*BC/BS OF LA*****BL
NM1*IL*1*DOE*JANE*R***MI*XUP4111111111
N3*111 LONG ROAD
N4*LAKE CHARLES*LA*71473
DMG*D8*19010101*M
NM1*PR*2*BC/BS OF LA*****PI*53120
N3*ATTN: CLAIMS DEPT*PO BOX 98029
N4*BATON ROUGE*LA*708989029
REF*2U*BCBS
CLM*0036558-1-01*286***11::1*Y*A*Y*Y*B
REF*G1*19D0000000
HI*BK:2382*BF:7048*BF:1101
LX*1
SV1*HC:88305*100*UN*1***1
DTP*472*RD8*20090403-20090403
REF*6R*0036558-1-01-400226106
LX*2
SV1*HC:11100*85*UN*1***1
DTP*472*RD8*20090403-20090403
REF*6R*0036558-1-01-400226107
LX*3
SV1*HC:99214:25*78*UN*1***2
DTP*472*RD8*20090403-20090403
REF*6R*0036558-1-01-400226104
LX*4
SV1*HC:87220*23*UN*1***3
DTP*472*RD8*20090403-20090403
REF*6R*0036558-1-01-400226105
SE*1801*0001
GE*1*1
IEA*1*000000032
********************

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                                BUSINESS RULES FOR PROFESSIONAL CLAIMS




Claims Submission Validation Reports (Claims transactions only)
Accepted/Not Accepted Reports
The disposition of Professional claims is detailed on the Accepted/Not Accepted Reports.
This series of reports provides detailed information on the claims that have detected errors
and those that have deleted errors. The detected errors are accepted by BCBSLA for
processing. All claims received are validated with a comprehensive set of business logic
edits. The Trading Partner is responsible for reviewing these reports and taking corrective
action on the deleted errors when necessary. We recommend you maintain these reports
for at least 60 days.

Accepted/Not Accepted Report for Facets Claims
The disposition of Professional claims is detailed on this Accepted/Not Accepted Report.
This series of reports provides detailed information on the claims that have been accepted
or not accepted by BCBSLA for processing. All claims received are validated with a
comprehensive set of business logic edits. The Trading Partner is responsible for reviewing
this report and taking corrective action when necessary. This report differs from the original
Accepted/Not Accepted Report because it will list all accepted claims as well as all not
accepted claims from a Trading Partner.

This process evaluates the submission at the claims level.
      Claims without errors are moved into the BCBSLA internal claims system for
      adjudication.
      Claims with non-critical errors may be moved into the BCBSLA internal claims
      system for adjudication.
      Claims with critical errors are deleted or rejected. These claims do not enter the
      processing system and must be corrected and retransmitted electronically for
      processing.
All claim transactions received Monday through Friday (except holidays) prior to 3 p.m.
(CST) will be processed in our daily processing cycle. Accepted/Not Accepted Reports are
available the following day by 9 a.m.

The Accepted/Not Accepted Reports include the following:
               Batch Summary Report (Batch Accepted or Not Accepted Report)
               Summary of Errors Detected Report
               Summary of Claims Processed With A Corrected Contract Number
               Summary of Claims Deleted
               Summary of Claim Details Deleted
It is extremely important to read the message at the end of each report category to
determine if corrective action is required.




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See Exhibits G thru L for examples of the Accepted/Not Accepted Reports The following
pages describe the various Claims Submission Validation Reports and indicates corrective
action for each report.

See Exhibit M for examples of the Activity Log

See Exhibit N for examples of the BCTPERR Report

See Exhibit O for examples of the new Accepted/Not Accepted Report for Facets claims.



Exhibit G: Notification of Batch Not Accepted


  BLUE CROSS/BLUE SHIELD OF LOUISIANA
REPORT: C0122R05 - A
FOCUS: D026
DATE: 03/18/2009 17.45.43 NOTIFICATION OF BATCH NOT ACCEPTED

SUBMITTER NAME - CONSOLIDATED RADIATION ONCOLOGISTS –JANE JONES
PROVIDER NUMBER      - 111111111
TOTAL CHARGES      - 2014.00
SUBMITTER NUMBER – 3A0000320
SUBMITTER STATUS - PRODUCTION
SUBMITTER CREATE DATE – 03/18/09
BC & BS OF LA PROCESS DATE – 03/18/09

REASON BATCH NOT ACCEPTED
-------------------------
DUPLICATE BATCH OF 03172009 RECEIVED 03172009


This report indicates that the entire batch/file was rejected. Pay special attention to the
REASON BATCH NOT ACCEPTED line. If DUPLICATE BATCH (as seen here), no further
action is required. For any other reason given, the entire batch (claim file) must be
retransmitted electronically.




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Exhibit H: Batch Accepted with No Errors



  BLUE CROSS/BLUE SHIELD OF LOUISIANA
REPORT: C0122R05 - B
FOCUS: D026
DATE: 03/18/2009 17.45.43 BATCH SUMMARY REPORT

SUBMITTER NAME - ASSOCIATED PEDIATRICS. – JANE DOE
SUBMITTER NUMBER – 3B0000320
SUBMITTER STATUS - PRODUCTION
SUBMITTER CREATE DATE - 03/18/09
BC & BS OF LA PROCESS DATE – 03/18/09

                          TOTAL           TOTAL
TOTAL        TOTAL        NUMBER          NUMBER
NUMBER       NUMBER       CLAIM           CLAIM             TOTAL
CLAIMS       CLAIM        DETAIL          DETAIL            AMOUNT
SENT         DETAIL       REJECTED        ACCEPTED          CHARGED          BATCH ACCEPTED
------       ------       --------        -----------       --------------    --------------
  24          33              0                33           2261.25                YES




This report indicates that the entire batch was accepted for processing. Review the
Summary of Errors Detected and/or Claims Processed with a Corrected Contract Number
reports (if present) to determine if corrective action is required for claims within the
submission.




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Exhibit I: Summary of Errors Detected


  BLUE CROSS/BLUE SHIELD OF LOUISIANA
REPORT: C0122R05 - C
FOCUS: D026
DATE: 03/18/2009 17.45.43 SUMMARY OF ERRORS DETECTED REPORT

SUBMITTER NAME - DR XPRESS HEALTHCARE SYSTEM-JOHN DOE
SUBMITTER NUMBER – 3C0000554
SUBMITTER STATUS - PRODUCTION
SUBMITTER CREATE DATE - 03/18/09
BC & BS OF LA PROCESS DATE - 03/18/09

PAY PROVIDER NAME – DOCTORS OF PLASTIC SURGERY
PAY PROVIDER NUMBER – 2222222220
PAY NPI NUMBER - 1234567890


PATIENTS           PATIENTS
ACCOUNT            NAME
NUMBER             LAST     F
--------           -------- --
515151             SHOTZ M SERVICE DT: 03/16/09
                               DETAIL REJ: NO
                               ERR FIELD: 70
                               ERR MESSAGE: INVALID DIAGNOSIS CODE
                               SERVICE DT: 03/16/09
                               DETAIL REJ: NO
                               ERR FIELD: 70
                               ERR MESSAGE: INVALID DIAGNOSIS CODE



MESSAGE:

THE ABOVE SERVICE(S) HAS BEEN ACCEPTED FOR PROCESSING. THIS REPORT IS
FOR NOTIFICATION OF AN ERROR DETECTED ON THE LISTED SERVICE.

DO NOT REFILE UNLESS ADDITIONAL CORRESPONDENCE IS RECEIVED FROM
BCBSLA. PLEASE CORRECT THE ERROR IN YOUR SYSTEM FOR FUTURE SUBMISSIONS.

This report indicates that, the system detected and corrected non-critical errors and
processed the claim. Although the claim has been corrected for processing, it is the
Trading Partner’s responsibility to make the system changes necessary to prevent these
errors from occurring in future transmissions.



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Exhibit J: Claims Processed with a Corrected Contract Number


  BLUE CROSS/BLUE SHIELD OF LOUISIANA
REPORT: C0122R05 - D
FOCUS: D026
DATE: 03/18/2009 17.45.43
    SUMMARY OF CLAIMS PROCESSED WITH A CORRECTED CONTRACT NUMBER

SUBMITTER NAME - EASY CLAIMS –JIM DOE
SUBMITTER NUMBER – 3D0000608
SUBMITTER STATUS - PRODUCTION
SUBMITTER CREATE DATE - 03/18/09
BC & BS OF LA PROCESS DATE - 03/18/09

PAY PROVIDER NAME - RADIOLOGY PROFESSIONALS
PAY PROVIDER NUMBER – 3333333330
PAY NPI NUMBER - 1234567890

PATIENTS      PATIENTS         INCORRECT                     CORRECTED
ACCOUNT       NAME             CONTRACT NUMBER               CONTRACT NUMBER
NUMBER        LAST          F RECEIVED                       USED TO PROCESS CLAIM
--------      --------      -  ---------------               ---------------------
WX010101      PATIENT       M ABC4242424246                   ABC4242424241
BC010202      SICK           I XYZ3636363636                  XYZ3636363631



MESSAGE:

THIS NOTIFICATION HAS BEEN SENT IN ORDER FOR YOU TO UPDATE YOUR SYSTEM
WITH THE CORRECTED CONTRACT NUMBER FOR THE PATIENTS LISTED ABOVE.

DO NOT REFILE THESE SERVICES, AS; ALL CHARGES HAVE BEEN PROCESSED WITH THE
CORRECTED CONTRACT NUMBER INDICATED.


This report indicates that the system corrected certain contract numbers before the claim
could be processed. It is the Trading Partner’s responsibility to update the contract
numbers identified in order to prevent these errors from occurring in future transmissions.




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                               BUSINESS RULES FOR PROFESSIONAL CLAIMS


Exhibit K: Summary of Claims Deleted

Refer to Appendix B: Not Accepted Error Definitions to determine how to correct or claims
found on this report.


  BLUE CROSS/BLUE SHIELD OF LOUISIANA
REPORT: C0122R05 - E
FOCUS: D026
DATE: 03/18/09 17.45.43 SUMMARY OF CLAIMS DELETED

SUBMITTER NAME - WORLDCLAIMS-JUDY DOE
SUBMITTER NUMBER – 3E0000623
SUBMITTER STATUS - PRODUCTION
SUBMITTER CREATE DATE – 03/18/09
BC & BS OF LA PROCESS DATE – 03/18/09

PAY PROVIDER NAME – STATEWIDE LABS LLC
PAY PROVIDER NUMBER – E0000
PAY NPI NUMBER - 1234567890

PATIENTS         PATIENTS
ACCOUNT          NAME
NUMBER           LAST           F
--------          --------      -
2BAAG0FG-0        BARBIE                   SERVICE DT:         02/05/09
                                           CLAIM CHG:            $65.36
                                           ERR FIELD:         42424242
                                           ERR MESSAGE: INVALID CONTRACT
                                                       NUMBER



SPECIAL REFILING INSTRUCTIONS:

MAKE THE CORRECTIONS AS INDICATED AND RESUBMIT THE ENTIRE CLAIM FOR
EACH PATIENT ACCOUNT LISTED.


This report identifies the claims with critical errors, which were not accepted into the
BCBSLA internal processing system. Only the claims that appear on this report must be
corrected and retransmitted electronically for processing.




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                                BUSINESS RULES FOR PROFESSIONAL CLAIMS


Exhibit L: Summary of Claims Details Deleted

Refer to Appendix B: Not Accepted Error Definitions to determine how to correct or claims
found on this report.

  BLUE CROSS/BLUE SHIELD OF LOUISIANA
REPORT: C0122R05 - F
FOCUS: D026
DATE: 03/18/09 17.45.43 SUMMARY OF CLAIM DETAILS DELETED

SUBMITTER NAME - INTERNET MEDICAL - JAMIE DODD
SUBMITTER NUMBER – 1F0000274
SUBMITTER STATUS - PRODUCTION
SUBMITTER CREATE DATE – 03/18/09
BC & BS OF LA PROCESS DATE – 03/18/09

PAY PROVIDER NAME -
PAY PROVIDER NUMBER - 151515151H
PAY NPI NUMBER - 1234567890

PATIENTS         PATIENTS
ACCOUNT           NAME
NUMBER           LAST     F
--------   -------- -
00CEF0-A-B        PATIENT M  SERVICE DT:                03/16/09
                                   DETAIL CHG:                  $840.00
                                   ERR FIELD:               151515151H
                                   ERR MESSAGE: INCOMPLETE PAY# WITH
                                              INV PERF
00DB0E-A-A      SICK     I   SERVICE DT:                03/16/09
                                   DETAIL CHG:                  $630.00
                                   ERR FIELD:               151515151H
                                   ERR MESSAGE: INCOMPLETE PAY# WITH
                                              INV PERF
00DC0D-A-A      DRIVER U           SERVICE DT:           03/16/09
                                   DETAIL CHG:                   $770.00
                                   ERR FIELD:                151515151H
                                   ERR MESSAGE: INCOMPLETE PAY# WITH
                                               INV PERF
SPECIAL REFILING INSTRUCTIONS:

MAKE THE CORRECTIONS AS INDICATED ABOVE AND RESUBMIT A CLAIM FOR THE
CLAIM DETAIL THAT CONTAINED THE ERROR. ANY CHARGE NOT LISTED ABOVE WAS
ACCEPTED FOR PROCESSING AND MUST NOT BE REFILED.

This report identifies the claim line items with critical errors, which were not accepted into
the BCBSLA internal processing system. Only the specific charge identified on this report
must be retransmitted for processing. The entire claim on this patient does not need to
be resubmitted.

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                                         December 9, 2009
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                                                  BUSINESS RULES FOR PROFESSIONAL CLAIMS


Exhibit L1: FACETS Accepted and Not Accepted Reports


                                                     Blue Cross and Blue Shield of Louisiana
                                                            Facets System to System
                                                            Professional Claims Report

SUBMITTER NUMBER: P0000ABC                                                     SUBMITTER NAME: New Clearinghouse
PROVIDER NUMBER: 123456789A             NPI NUMBER: 1234567890
PROVIDER NUMBER: 12354                                                         PROVIDER NAME: John Doe, MD
RECEIVE DATE: 03/18/09                                                         PROCESSING DATE: 03/18/09


      837P NOT ACCEPTED REPORT

PAGE 1

PATIENT             PATIENT             PATIENT      BC CONTRACT        FROM          THRU       CLAIM    ERROR DATA
ACCOUNT NUM         LAST NM             FIRST NM     NUMBER             DATE          DATE       AMOUNT DESCRIPTION
________________________________________________________________________________________________________________________________
702454              MUSSER              JACOB        213456789   031609       031609     20.00 INVALID TOTAL CHARGE
702518              ROLAND              08120550     282163000   031609        031609    315.00 PATIENT DATE OF BIRTH
                                                                                                IS INCORRECT 3/3/19
702585              DEPAU               08120550    2C0018000    031609        031609    75.00 PATIENT DATE OF BIRTH
                                                                                                IS INCORRECT 6/5/19
702831              SHIRLEY            08120550    282747000     031609        031909    145.00 PATIENT DATE OF BIRTH
                                                                                                IS INCORRECT 4/3/19

TOTAL CLAIMS ACCEPTED:                                                          8 CLAIMS FOR $910.00
TOTAL CLAIMS NOT ACCEPTED:                                                      4 CLAIMS FOR $555.00
TOTAL CLAIMS:                                                                   12 CLAIMS FOR $1,465.00




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                                                           December 9, 2009
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                                                  BUSINESS RULES FOR PROFESSIONAL CLAIMS


                                               Blue Cross and Blue Shield of Louisiana
                                                      Facets System to System
                                                     Professional Claims Report

SUBMITTER NUMBER: P0000ABC                                                     SUBMITTER NAME: New Clearinghouse
PROVIDER NUMBER: 123456789A             NPI NUMBER: 1234567890
PROVIDER NUMBER: 12354                                                         PROVIDER NAME: John Doe, MD
RECEIVE DATE: 03/18/09                                                         PROCESSING DATE: 03/18/09


      837P ACCEPTED REPORT                                                                                          PAGE 1

PATIENT            PATIENT      PATIENT              BC CONTRACT               FROM THRU     CLAIM   CH TRACKING
ACCOUNT NUM        LAST NM      FIRST NM             NUMBER                    DATE DATE AMOUNT  NUMBER

___________________________________________________________________________________________________
701763              HEDGEMON HELEN                  226036000            031609 031609      95.00             081205500462412
701774              CRNKO        LAURA              239786000            031609 031609      145.00            081205500462409
702071              BARNETT     LISA                276640000            031609 031609      65.00             081205500462436
702276              SHARP        DARWIN             276271000           031609 031609       95.00             081205500462415
702329              NETTLES     CLAIRE              200180000           031609 031609       145.00            081205500462414
702366              SHARP        DARWIN             276271000            031609 031609      125.00            081205500462437
702775              MATTHEWS FRED                   282265000           031609 031609       95.00             081205500462396
703046              BROCK        RICKY              283576000           031609 031609       145.00            081205500462472

TOTAL SERVICE LINES ACCEPTED                                            25
TOTAL SERVICE LINES NOT ACCEPTED                                               4

TOTAL CLAIMS ACCEPTED:                                                          8 CLAIMS FOR $910.00
TOTAL CLAIMS NOT ACCEPTED:                                                      4 CLAIMS FOR $555.00
TOTAL CLAIMS:                                                                   12 CLAIMS FOR $1,465.00




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                                                           December 9, 2009
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                                BUSINESS RULES FOR PROFESSIONAL CLAIMS


Exhibit M: Activity Log

**********************************************************************
       LOG batch for remote user : T0001098
***********************************************************************

Wed May 7 08:25:11 2003
   Add with protocol=ASYNC: ID=T0001111, BID="X12Claims.in"
      ...... Added successfully, bytes=36342, batch No.=638

Wed May 7 09:37:08 2003
   Add with protocol=ASYNC: ID=T0001111, BID="X12Claims.in"
      ...... Added successfully, bytes=16334, batch No.=640

Wed May 7 09:43:23 2003
   Add with protocol=ASYNC: ID=T0001111, BID="X12Claims.in"
      ...... Failed, returned error code=1

Wed May 7 15:17:53 2003
   Extract with protocol=FTP: ID=T0001111, BID="#0000639"......
             Extracted ID=T0001011, BID="<<ACTIVITY LOG>>", bytes=653, batch
No.=639
      ...... Successfully extracted 1 batch(es).


Exhibit N: BCTPERR Report

The BCTPERR Report will display an error message at the beginning of the file. See
boxed area below:

ERROR --->>>> Mailbox ID does not match Trading Partner ID within the file Submitted
<<<<ISA*00*1234567890*00*1234567890*ZZ*T0000014      *ZZ*BCBSLA001
*030601*1907*U*00401*000000032*0*T*<~
GS*HC*T0000014*RECEIVER CODE*20030601*1907*1*X*004010X098A1~
ST*837*0001~
BHT*0019*00*0001*20030601*1907*CH~
REF*87*004111111A1~
NM1*41*2*HEALTH CLINIC &*****46*T0000011~
PER*IC*RON DAVID*TE*3333333332~
NM1*40*2*BLUE CROSS BLUE SHIELD*****46*11111~
HL*1**20*1~
PRV*PT*ZZ*203BF0100X



Trading Partners that receive the BCTPERR report must correct the Trading
Partner ID and retransmit the entire file.




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                                         December 9, 2009
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                              BUSINESS RULES FOR PROFESSIONAL CLAIMS




VII. 835 Remit Process
Many trading partners utilize the electronic HIPAA 835 electronic remit retrieval process
to post their payments electronically. These remits will always be dated for Monday’s.
Depending on any 835 issues at BCBSLA, the remit pickup time frame could vary. The
timeframe for retrieving your remits are as follows:


                               835 REMIT AVAILABILITY

                 LEGACY                           Monday by 2:00 pm
                 FACETS                           May be available on Monday by 2:00 pm.
                                                  If not, Tuesday @ noon.

If you are unable to retrieve your 835 file at the above timeframes:

   1) Check the ILinkBlue system using the Remittance Advice application to
      determine if the paper payment register has been posted.
   2) If the paper registers are not posted, this indicates that the 835 files will not be
      available.
   3) Check the ILinkBlue messages to determine if there is a notification alerting you
      to the delay.
   4) If not, contact EDI Clearinghouse Support (edich@bcbsla.com) and expected
      timeframe for availability.

If you are missing one or more 835 files:

   1) If your paper remittances are posted and the above timeframes are not met for
      the general population, EDI will proactively notify by email trading partners and
      providers. If you are not able to retrieve your 835 remits by Wednesday morning
      and have not been contacted or no message has been placed on the ILinkBlue
      information board, please contact our EDI Support area at 225-291-4334 or email
      us at edich@bcbsla.com.




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                             BUSINESS RULES FOR PROFESSIONAL CLAIMS




VIII. Not Accepted Claims Error Report Codes
The disposition of professional claims is detailed on Not Accepted Claims Report
specifically “Summary of Claims Deleted and Summary of Claims Details Deleted.
These reports provide detailed information on the claims that have not been accepted
by BCBSLA for processing.

Trading Partners are responsible for monitoring these reports and taking corrective
action when necessary. These reports identify claims with critical errors, which were
not accepted for processing. All claims that appear on the Summary of Claims Deleted
or Summary of Claim Details Deleted must be corrected and retransmitted for
processing.

The Error Description field on this report contains a descriptive summary of why the
claim was not accepted for processing. When possible, the Error Data field will contain
the specific code/data found on the claim, which caused the error. Both fields should
assist you in making corrections to the claim. This section lists the errors that appear
on not accepted reports and a detailed description to assist with error resolution.




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                           BUSINESS RULES FOR PROFESSIONAL CLAIMS



Not Accepted Error Report Codes
ACTUAL NUMBER OF UNITS REQUIRED

     If CPT4 = A4644 - A4647, Units of Service must be greater than 1.

ADJUSTMENT CLAIM ALREADY IN SYSTEM

     If a claim is an adjustment claim and an ICN number is present, please allow the
     original adjustment to process prior to submitting another adjustment for this
     claim

ANESTHESIA MINUTES INVALID

     Anesthesia minutes cannot be equal to 0 or 1, unless CPT code is equal to
     01996, 01999, 01968, or 01995.

BMULTNPI

     The Billing (pay provider) NPI on the claim is found in the BCBSLA system, but
     the NPI crosswalk to the BCBSLA Legacy numbers finds multiple providers that
     crosswalk back to this NPI.

BNONPI

     The billing (pay provider) NPI on the claim is not set up or found in the BCBSLA
     system. Provider should contact the BCBSLA Provider Credentialing area to
     have their NPI number set up at 1-800-716-2299 before resubmitting claims.

BNOTAXON

     The billing (pay provider) NPI number information on the claim requires a
     taxonomy code to assist the system logic in finding a single Legacy provider
     number.

BNPITAXNF

     The Billing (pay provider) NPI and tax combination cannot be found in the
     BCBSLA system.




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                                    December 9, 2009
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                            BUSINESS RULES FOR PROFESSIONAL CLAIMS



Not Accepted Error Report Codes
BTAXONNTBC

     The Billing (pay provider) NPI on the claim is found in the BCBSLA system, but
     the NPI crosswalk finds more than one provider number that crosswalks back to
     this NPI. A taxonomy code is present on the claim; however, that taxonomy code
     is not currently used in our logic and therefore a single provider number match
     cannot be found.

CONTRACT SECONDARY TO MEDICARE

     The contract number submitted on this claim is supplemental to Medicare. The
     claim must be filed with Medicare and they will automatically crossover the
     BCBSLA portion for processing. If the claim did not crossover from Medicare,
     please send a paper claim along with the Medicare EOB for processing.

CPT4 01968 MUST HAVE 01967

     If CPT4 code 01968 is present on claim, then CPT4 01967 must also be present.
EMC AGREEMENT NOT ON FILE

     BCBSLA does not have an electronic media claims agreement (A2 Business
     Profile) on file for this provider. Please contact the BCBSLA EDI Clearinghouse
     Support Line at 225-291-4334 to have them forward you an A2 Provider
     Agreement. Complete the form and fax to the EDI area at 225-298-2945 to have
     the provider set up.

FILE EACH DOS SEPARATELY

     The from and thru dates on the claim must be equal when the CPT4 code is
     equal to 95115, 95117, 95120, 95125, 95130, 95131, 95132, 95133, 95134,
     95199, 95144, 95146, 95147, 95148, 95149, 95165, 95170, or 95180.

FOURTH DIAGNOSIS CODE INVALID

     The fourth diagnosis code on the claim is invalid or not effective for the date of
     service submitted on the claim. Correct diagnosis and resubmit claim.

FROM DOS IS GREATER THAN ENDING DOS

     The “from” date of service cannot be greater than the “thru” date of service.
     Make corrections and resubmit claim.



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                                     December 9, 2009
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Not Accepted Error Report Codes
INV OR BLANK PERF PROVIDER NUM

     The performing provider number is not on file at BCBSLA. Provider must have a
     valid BCBSLA provider number on file with BCBSLA to submit claims.

INVALID CONTRACT NUMBER

     The patient’s contract number (subscriber ID) submitted on the claim is invalid.
     Verify contract number and resubmit claim with corrected contract number.

INVALID CPT4 CODE

     The CPT4 code submitted on the claim is either not found, not effective, or is not
     a valid code. Unlisted CPT codes which end in ‘49’ or ‘99’ cannot be used. For
     FEP claims, the CPT 90841 cannot be used since it does not specify the length
     of session. Please resubmit claim with a valid CPT4 code.

INVALID CPT4 MODIFIER COMBINATION

     1. If CPT code 10000 thru 69999 is present on claim with a modifier, the
        modifier must be equal to 20, 22, 26, 32, 47, 50-56, 58, 59, 62, 66, 74-82, 90,
        99, or 60.

     2. If CPT code is 90000 thru 99100 is present on claim with a modifier, the
        modifier must be equal to 21, 22, 24-27, 32, 51, 52, 55, 56, 58, 59, 75-79, 90
        or 99.

     3. If CPT code is 99201 thru 99456 is present on claim with a modifier, the
        modifier must be equal to 21, 22, 24, 25, 27, 32, 52, 55-59, 78, 79, or 90.

     This edit should be applied for all modifiers 1-4.

INVALID CPT4 MODIFIER PCTC COMBINATION

     The claim has an invalid CPT4/modifier combination.

INVALID DIAGNOSIS CODE

     The primary diagnosis code is invalid or not effective for the date of service on
     the claim. Correct diagnosis and resubmit claim.




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                                      December 9, 2009
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                             BUSINESS RULES FOR PROFESSIONAL CLAIMS



Not Accepted Error Report Codes
INVALID DIAGNOSIS CODE POINTER

      The DIAGNOSIS POINTERS must be numeric characters 1-4. The diagnosis
      pointer or ICD-9 codes cannot point to a blank diagnosis code. The pointer
      should identify the diagnosis sequence that corresponds to the line item
      procedure.

INVALID DIAG POINTER, NO DIAG7 PRESENT
     The DIAGNOSIS POINTERS must be numeric characters 1-4. The diagnosis
     pointer or ICD-9 codes cannot point to a blank diagnosis code. The pointer
     should identify the diagnosis sequence that corresponds to the line item
     procedure.

INVALID DIAG POINTER, NO DIAG8 PRESENT
     The DIAGNOSIS POINTERS must be numeric characters 1-4. The diagnosis
     pointer cannot point to a blank diagnosis code. The pointer should identify the
     diagnosis sequence that corresponds to the line item procedure.

INVALID FROM DATE OF SERVICE

      The “from” date of service cannot be greater than the current date of service on
      the claim and must be in a valid format. Correct date and resubmit claim.

INVALID MODIFIER - CPT4/HCPCS/PCTC COMBINATION

      The claim has an invalid modifier/CPT4 combination.

INVALID MODIFIER POT COMBINATION

      The claim has an invalid modifier/place of treatment combination.




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                                      December 9, 2009
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                             BUSINESS RULES FOR PROFESSIONAL CLAIMS



Not Accepted Error Report Codes
INVALID NEWBORN NAME

     When filing a claim for a newborn baby, the patient’s first name cannot be BABY,
     BABYBOY, BABYBOY1, BABYBOY2, BABYBOY3, BABYBOY4, BABYGIRL,
     BABYGIRL1, BABYGIRL2, BABYGIRL3, BABYGIRL4, BABY1, BABY2, BABY3,
     BABY4, GIRL,BOY, BOY1, BOY2, BOY3, BOY4, GIRL1, GIRL2, GIRL3, GIRL4,
     INFANT, TWIN, TWIN1, TWIN2, NEWBO, INFANT1, INFANT2, INFANT3,
     INFANT4, BAB, BAB1, BAB2, BAB3, BAB4, BABYG, BABYB, UNKNOWN, or
     TRIPLET unless the patients’ age is greater than one. The claim must be filed
     with a valid name of the patient.

INVALID NUMBER OF UNITS

     If the thru date of service on the claim is greater than the from date of service,
     then the units cannot be equal to one if the CPT code is one of the following:
     A4927, 77419, 77420, 77425, 77430, 77431, 77432, 77427, 86421, 86422,
     90781, 90830, 90918-90921, 90995, 92984, 95004, 95010, 95015, 95024,
     95028, 95040 to 95044, 95155, 95165, 95180, 95810, 95811, 95900, 95904,
     95937, 95950, 95952, 96412, 96423, 97145, 97003, 97004, 97221, 97241,
     97261, 97501, 97521, 97531, 97541, 97535, 97537, 97542, 95180, 95810,
     97701, 97721, 99190, 99191, 99192, 95903, 99291, or 99292

INVALID PATIENT RELATIONSHIP TO SUB

     The relationship to the insured must be SE, HU, WI, or DE. The relationship
     code cannot be WI if the sex is a male (M) and cannot be HU if the sex is a
     female (F).

INVALID PATIENT SEX CPT4

     Sex cannot be male if the following CPT4 codes are listed on the claim: 19160,
     19180, 19182, 19220, 19316, 19318, 19324, 19325, 19330, or 56405-59899.
     Sex cannot be female if the following CPT4 codes are listed on the claim: 19140,
     52649, or 54000-55899

INVALID PATIENT SIGNATURE IND

     The patient’s signature indicator on the claim must be equal to a Y or an N.




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                                      December 9, 2009
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                              BUSINESS RULES FOR PROFESSIONAL CLAIMS



Not Accepted Error Report Codes
INVALID PAY PROVIDER

      The billing provider number or pay provider number on the claim is not a valid
      BCBSLA provider number and approved for electronic submission or the valid
      BCBSLA provider number is not effective for the date of service on the line item
      or claim.

INVALID PLACE OF SERVICE

      The place of service on the claim must be equal to the following: 11, 12, 20, 21,
      22, 23, 24, 25, 31, 32, 34, 41, 42, 49, 51, 52, 55, 60, 61, 62, 65, 71, 72, or 81.
      This edit will also be issued if the facility type is not one of the places of service
      listed above or the place of service and facility type are both empty. This is valid
      for both professional and dental claims at the claim and line level .

INVALID POS CPT4 COMBINATION

      The place of service on the claim must be compatible with the CPT4 codes as
      indicated in the guideline below:

             CPT CODE                     PLACE OF SERVICE
             G9141-G9142           60
             90465-90474           60
             90655-90660           60
             90663                 60
             99201-99220           11, 22, 23, 62, 65, 71, 72, or 81
             99201-99215           11, 20, 22, 23, 24, 50, 60, 62, 65, 71, 72, or 81
             99221-99238           21, 25, 31, 51, 52, 55, 56, or 61
             99221-99238           21, 22, 23, 24, 25, 32, 51, 52, 55, 56, 61 or 62
             99241-99245           11, 12, 22, 23, 24, 32, 33, 62, 65, 71, 72, or 81
             99241-99245           11, 22, 23, 24, 32, 34, 50, 60, 62, 65, 71, 72, or 81
             99251-99263           21, 25, 31, 51, 52, 55, 56, or 61
             99251-99263           21, 22, 23, 24, 25, 32, 51, 52, 55, 56, 61 or 62
             99281-99285           22, 23 or 24
             99301-99333           31, 32
             99341-99353           12 or 34

INVALID PREFIX FOR DATE OF SERVICE
     The contract number prefix in the INSURED’S ID NUMBER field is invalid or
     cannot be processed by BCBSLA. Verify you have entered the correct prefix. If
     the prefix has been entered as shown on the subscriber’s ID card, verify the filing
     instruction’s on the back of the card. Contract number prefix invalid for date of
     service error will apply only to out of state contracts.


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                              BUSINESS RULES FOR PROFESSIONAL CLAIMS



Not Accepted Error Report Codes
INVALID THRU DATE OF SERVICE

      The “thru” date of service on each line item must be a valid date that is equal to
      the “from” date of service or is after the “from” date.

INVALID TIMES-NUMBER OF SERVICES

      If the thru date of service on the claim is greater than the from date of service
      then the units cannot be equal to one, unless the CPT code is one of the
      following: A4927, 77419, 77420, 77425, 77430, 77431, 77432, 77427, 86421,
      86422, 90781, 90830, 90918-90921, 90995, 92984, 95004, 95010, 95015,
      95024, 95028, 95040 to 95044, 95155, 95165, 95180, 95810, 95811, 95900,
      95904, 95937, 95950, 95952, 96412, 96423, 97145, 97003, 97004, 97221,
      97241, 97261, 97501, 97521, 97531, 97541, 97535, 97537, 97542, 95180,
      95810, 97701, 97721, 99190, 99191, 99192, 95903, 99291, or 99292

INVALID TOTAL CHARGE

      The total charge field must equal to the sum of all the line item charges on the
      claim and must be greater than zero.

NEED ANESTHESIA CPT4 FOR ANESTHESIA CLM

      An anesthesia CPT4 must be present for an anesthesia claim. If CPT code is not
      equal to 0 and does not end with an alpha character and one of the following
      modifiers is present 23, P1, P2, P3, P4, P5, P6, P7, AA, AD, QK, QS, QX, GC,
      G8, G9, QY, QZ, 30 or 47, this edit will be issued.

OUT OF STATE CONT DHH FILE PAPER CLAIM (MEDICAID)
     This is a Medicaid claim and must be filed on paper (will apply only to out of state
     contracts)

PATIENTS DATE OF BIRTH IS INCORRECT

      The patient’s date of birth is incorrect. Verify date of birth and resubmit claim.

PATIENT NAME DOES NOT MATCH NAME ON BC SYS

      The patient’s name on the claim does not match the name on the contract on the
      BCBSLA system. The patients first and last name must match the first three
      positions exactly.




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                                       December 9, 2009
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                             BUSINESS RULES FOR PROFESSIONAL CLAIMS



Not Accepted Error Report Codes
PATIENT RELATIONSHIP CODE IS INCORRECT

     The relationship to the insured field is editing against the eligibility records at
     BCBSLA. If the relationship to the insured is correct, verify that the sex of the
     patient is also entered correctly.

PERF PROV CANNOT = CLINIC

     The performing provider number cannot be the clinic number (in-state general
     type 08). The doctor’s regional performing provider number must be used. Enter
     the individual provider number of the provider who performed the services.

RMULTNPI

     The rendering (performing provider) NPI on the claim is found in the BCBSLA
     system, but the NPI crosswalk to the BCBSLA Legacy numbers finds multiple
     providers that crosswalk back to this NPI.

RNONPI

     The rendering (performing provider) NPI on the claim is not set up or found in the
     BCBSLA system. Provider should contact the BCBSLA Provider Credentialing
     area to have their NPI number set up at 1-800-716-2299 before resubmitting
     claims.

RNOTAXON

     The rendering (performing provider) NPI number information on the claim
     requires a taxonomy code to assist the system logic in finding a single Legacy
     provider number.

RNPITAXNF

     The rendering (performing provider) NPI and tax combination cannot be found in
     the BCBSLA system.

RTAXONNTBC

     The rendering (performing provider) NPI on the claim is found in the BCBSLA
     system, but the NPI crosswalk finds more than one provider number that
     crosswalks back to this NPI. A taxonomy code is present on the claim; however,
     that taxonomy code is not currently used in our logic and therefore a single
     provider number match cannot be found.


                                              51
                                      December 9, 2009
                               BLUE CROSS BLUE SHIELD OF LOUISIANA
                             BUSINESS RULES FOR PROFESSIONAL CLAIMS



Not Accepted Error Report Codes
SECONDARY DIAGNOSIS CODE INVALID

     The secondary diagnosis code is invalid or not effective for the date of service.
     Correct diagnosis and resubmit claim.

TERTIARY DIAGNOSIS CODE INVALID

     The tertiary diagnosis code is invalid or not effective for the date of service.
     Correct diagnosis and resubmit claim.

UNSPECIFIED CPT REQUIRES HARDCOPY WITH EXPLANATION

  1. If the charge is greater than $500 and CPT ends in 99, except for CPT 26499,
     27499, 28299, 29899, 63199, 83499, 87799, or 99299, the claim must be
     submitted on paper (hardcopy) with an explanation.

  2. If the CPT code is equal to J3490 and J9999 and the charge is greater than
     $500, the claim must be submitted on paper (hardcopy) with an explanation.

  3. If the CPT code is 21089, 23929, 26989, 37501, 38129, 38589, 43289, 43659,
     44238, 44239, 44979, 47379, 47579, 49329, 49659, 50549, 50949, 55559,

  4. 58578, 58579, 58679, 59897, 59898, 60659, 69949, 69979, 76496, 76497,
     76498, 86849, 89240, 90749, 92700, 96549, 97039, 97139, 99429, 99600,
     A4335, A4421, A4649, A4913, A6261, A6262, B9998, D0502, L3649, L8039,
     L8239, V2629 and the charge is greater than $500, the claim must be submitted
     on paper (hardcopy) with an explanation.

VERIFY ASSISTANT CREDENTIALS

     These charges are being filed with the provider number of the physician assistant
     (PA). Re-file the claim with the 10-position individual BCBSLA provider number
     of the supervising physician and the appropriate modifier code of AS.

5th DIAGNOSIS CODE INVALID

     The fifth diagnosis code is invalid or not effective for the date of service. Correct
     diagnosis and resubmit claim.

6th DIAGNOSIS CODE INVALID

     The sixth diagnosis code is invalid or not effective for the date of service. Correct
     diagnosis and resubmit claim.


                                              52
                                      December 9, 2009
                              BLUE CROSS BLUE SHIELD OF LOUISIANA
                            BUSINESS RULES FOR PROFESSIONAL CLAIMS



Not Accepted Error Report Codes
7th DIAGNOSIS CODE INVALID

     The seventh diagnosis code is invalid or not effective for the date of service.
     Correct the diagnosis and resubmit the claim.

8th DIAGNOSIS CODE INVALID

     The eighth diagnosis code is invalid or not effective for the date of service.
     Correct diagnosis and resubmit the claim.




                                             53
                                     December 9, 2009

								
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