1. Blue Cross and Blue Shield of Nebraska is an Independent Licensee of the Blue Cross and Blue Shield Association. Timely Filing and Corrected Claims October 21, 2015

2. Agenda Timely Filing Limits Timely Filing Exceptions Provider Compliance – Requirements Member Benefit - Liability Rejected – Returned Claims Replacement Claims – Electronic & Paper Appeal-Reconsideration Requirement 2

3. Timely Filing Limits Provider is responsible for clean claims, Adjustments or revisions to timely filed claims Timeframe specified according to agreement –120 days –180 days –Master Group Application or Summary Plan Description The time limit is set forth from the date of service FEP follows the same timely filing requirements 3

4. Timely Filing Limits Exceptions Coordination of Benefits - Timely filing begins from the processed date of the claim noted on the primary payer’s Explanation of Benefits. Subrogation Workman Compensation Obstetrical (OB)/partial care or transfer of care Fraud, waste, abuse or intentional misconduct 4

5. Provider Compliance Requirement Providers are contractually responsible to file claims, adjustments or revisions in a timely manner. If a claim for a covered person is not filed originally within the timeframe and in compliance with BCBSNE Policies and Procedures no benefits will be paid. Provider agrees that no payment will be pursued from the covered person for any service not submitted in compliance with the timely filing terms of their agreement. Adjustments or revisions to timely filed claims must be made within 12 or 18 months from the last payment 5

6. Timely Filing – Member Benefits When verifying benefits for any BCBS member, verify timely filing limitations. If a copay is collected from the member at the time of service and the claim is denied for timely filing the copay does not have to be refunded to the member. If money for deductible or coinsurance is collected at the time of service from the member and the claim is denied for timely filing either or both must be refunded to our member. The entire claim is denied as timely filing. 6

7. Timely Filing – Member Liability It is the member’s responsibility to present a current identification card or provide verification of coverage with the correct insurance information in order for the provider to file a clean claim. When a member withholds information preventing a provider from filing a timely claim then do not file the claim for the patient/member because the claim will deny as provider liability. The member is responsible and should be billed for the charges when withholding information needed to file the claim after the provider has made written attempts to obtain the insurance information. 7

8. Clean Claim Definition BCBSNE requires providers to submit clean claims for all services provided promptly and in the format requested regardless if there are other sources of payment or reimbursement A clean claim is for health care services provided to a covered person by a provider on a UB04 or CMS 1500 (or successor form) or an electronic form in compliance with BSBSNE Policies and Procedures. All required fields must be completed with all information necessary to adjudicate the claim. A claim that rejects electronically or is returned to the provider with an “action needed letter” is not considered a clean claim 8

9. Rejected – Returned Claims Do not send a claim with “corrected claim” or “replacement claim” written or typed on the claim itself, as it will be returned to be resubmitted correctly. If a claim submission is rejected due to incorrect or invalid information, it is the provider responsibility to make the necessary corrections and resubmit the claim within a timely filing period. Claim rejected electronically or returned is not considered a clean claim and not accepted as proof of timely filing. 9

10. Replacement – Electronic Corrected Claims In order to submit a corrected claim or a resubmission of an electronic claim you need to modify the new transaction. The original claim number must be in the 2300 REF*8 segment. This is an industry standard process. When creating the 837 file place a value of 5 (Late Charges – Institutional use only), 7 (Replacement Claim) or 8 (Void/Cancel of Prior Claim) in the 2300 CLM 05-3 element. Claims submitted and processed under an incorrect patient/or member identification (ID) number will need to be voided before a new claim is submitted. Resubmit the claim as it was originally submitted but with claim frequency of code 8 to void. Then resubmit corrected claim using claim frequency code 1. 10

11. Replacement – Paper Corrected Claims Corrected paper claims must be filed to BCBSNE attached to a Reconsideration Request Form. Place a value of 7 or 8 in Box 22 on the CMS 1500 claim form. Include the original claim number in the Original Reference Number field located to the right side of Box 22 on the CMS 1500. Corrected electronic claims that require attachments (other insurance information, medical records or an invoice) must be filed as a paper claim attached to a Reconsideration Request Form. 11

12. Appeal – Reconsideration Requests The Reconsideration Form is used for timely filing exceptions: –Subrogation –Workman Compensation –Coordination of Benefits The appeal form is not used for timely filing denials. The Appeal/Reconsideration Request Form is located at: www.nebraskablue.com/providerswww.nebraskablue.com/providers 12

13. Top Ten Claim Rejections Duplicate claim found Medicare primary claims cannot be accepted until 30 days from adjudication date Policy number does not have coverage for medical services Subscriber’s last name missing or misspelled BCBSNE cannot accept claims for this policy for the service date(s) provided Billing tax ID not found ICD-10 coding error Accident related injury indicator missing or invalid Subscriber ID not on membership file Patient is not on membership file OR the patient name or date of birth does not match 13

14. Questions? 14