September 20, 2013

Update Edit Logic and Edit Codes added. Blue Cross and Blue Shield Association Medicare Coordination of Benefits Claims

ASK will implement new edits in response to Blue Cross and Blue Shield Association (BCBSA) requirements to ensure Medicare COB claims are allowed sufficient time to automatically process. The following payers will be impacted:

  • BCBSKC (47171)
  • Highmark Western and Northeastern New York (55204, 00800, 00301, 00801)

Purpose:  This is an effort by BCBSA to stop duplicate claims that result in additional unnecessary work and may result in inaccurate claims processing.

If Medicare returns MA18 or N89 on the remittance advice this indicates the claim has automatically crossed to the secondary payer. Claims with these remark codes should not be filed to the secondary payer prior to 30 days from the date of Medicare remittance advice.  This will allow for sufficient time for claims to automatically process.

The payer remittance advice contains all necessary adjudication (processing) information needed by subsequent payer(s) to accurately process the claim. All Primary adjudication information must be included on a Secondary claim.

 The following claim types will be excluded from this editing:

  • VA claims
  • Claims with a GY modifier

For billing instruction contact your Blue Cross and Blue Shield payer.

Note:  In some instances practice management software will automatically produce a secondary claim, either electronic or paper, upon posting of the primary payment.
This could result in duplicate claims that will reject with this new editing. Providers are encouraged to contact their software vendor or billing service to review the secondary process.

Institutional Edit Logic and Edit Codes:

Are any of the following true:

  • If 2010AA NM109 equals BCBSKS.VA_NPI; or
  • 2400 SV202-3, SV202-4, SV202-5, SV202-6 equal ‘GY’; or

If yes, accept. (Claim should not be subjected to remainder of edit).
If no, are all of the following true:

  • 2320 SBR01 = ‘P’;
  • 2000B SBR01 = ‘A’ thru ‘H’, ‘S’ or ‘T’;
  • 2320 SBR09 = ‘MA’

If no, accept.  (Claim is not Medicare Primary and should not be subjected to remainder of edit).
If yes, if any of the following fields are present:

            2320 MIA05                   2320 MOA03
            2320 MIA20                   2320 MOA04
            2320 MIA21                   2320 MOA05
            2320 MIA22                   2320 MOA06
            2320 MIA23                   2320 MOA07
                 
does the value in the present field equal ‘MA18’ or ‘N89’.

If no, accept.   (Claim is Medicare Primary, but not crossover).
If yes, is 2320 AMT01 = ‘D’?

If no, accept.
If yes, is 2430 SVD loop present for this payer?
If yes, skip to 2430 DTP Date Compare (below).
If no, is the 2330B DTP (with ‘573’ qualifier) present?
If yes, skip to 2330B DTP Date Compare (below).
If no, reject.   A6:516:PRP Medicare Remittance date is missing.

2330B DTP Date Compare:  if present, is the value in the 2330B DTP03 at least 30 days prior to date of claim receipt.

If no, reject.  A3:78 – Duplicate Claim – Medicare remit date < 30 days from claim receipt date.
If yes, accept.

2430 DTP Date Compare:  if present, is the date value in the 2430B DTP03 (where payer id in 2430 SVD equals the payer id in 2330B NM109) at least 30 days prior to date of claim receipt.

If no, reject.   A3:78 – Duplicate Claim – Medicare remit date <30 days from claim receipt date.

If yes, accept.

Professional Edit Logic and Edit Codes:

Are any of the following true:

  • If 2010AA NM109 equals BCBSKS.VA_NPI (valuelist); or
  • 2400 SV101-3, SV101-4, SV101-5 or SV101-6 equal ‘GY’;

If yes, accept.  (Claim should not be subjected to remainder of edit).
If no, are all of the following true:

  • 2320 SBR01 = ‘P’;
  • 2000B SBR01 = ‘A’ thru ‘H’, ‘S’ or ‘T’;
  • 2320 SBR09 = ‘MB’;

If no, accept.  (Claim is not Medicare Primary and should not be subjected to remainder of edit).
If yes, if any of the following fields are present:

2320 MOA03
2320 MOA04
2320 MOA05
2320 MOA06
2320 MOA07

Does the value in the present field equal ‘MA18’ or ‘N89’?

If no, accept.   (Claim is Medicare Primary, but not crossover).
If yes, is 2320 AMT01 = ‘D’?

If no, accept.
If yes, is a 2430 SVD loop present for this payer?  (payer id in 2430 SVD01 = payer id in 2330B NM109 where 2320 SBR09 = MB)
If no, reject.   A6:643 Missing Service Line Pd. Amt.
If yes, is the date value in the 2430B DTP03 (where payer id in 2430 SVD = payer id in 2330B NM109 where 2320 SBR09 = MB) at least 30 days prior to date of claim receipt.

If no, reject.   A3:78 Duplicate Claim –Medicare remit date < 30 days from claim receipt date.
If yes, (if payer id in 2430 SVD01 = payer id in 2330B NM109 where 2320 SBR09 = MB), if the value in 2430 SVD02 is not equal to 2400 SV102, is the 2430 CAS segment present?
If no, reject.  A6:521 / A6:519 – Missing Medicare CAS segment.

If yes, (using that same 2430 loop related to MB Primary) does 2430 CAS01 = ‘PR’?

If no, accept.  If yes, does:
2430 CAS02 = ‘2’? If no, accept.  If yes, does 2430 CAS03 equal the value in 2400 SV102?
2430 CAS05 = ‘2’? If no, accept.  If yes, does 2430 CAS06 equal the value in 2400 SV102?
2430 CAS08 = ‘2’? If no, accept.  If yes, does 2430 CAS09 equal the value in 2400 SV102?
2430 CAS11 = ‘2’? If no, accept.  If yes, does 2430 CAS12 equal the value in 2400 SV102?
2430 CAS14 = ‘2’? If no, accept.  If yes, does 2430 CAS15 equal the value in 2400 SV102?
2430 CAS17 = ‘2’? If no, accept.  If yes, does 2430 CAS18 equal the value in 2400 SV102?

If no, accept.

If yes, reject.   A8:583 / A8:519 – Line Charge cannot = Medicare Adjustment Amount.