Important News:

Regence began accepting revised CMS-1500 (08-05) claims forms January 1, 2007.
We will continue to accept the CMS-1500 (12-90) claim form allowing use of existing stock. Once obtained, our expectation is that you begin using the revised CMS-1500 (08-05) claim form. Obtain this revised form by contacting your current supplier. For a negative or PDF version of the revised form, direct your supplier to:

• The Government Printing Office at (202) 512-0455
• TFP Data Systems at 1500form@tfpdata.com or 1 (800) 482-9367 ext. 1770

No supplier? Visit the Web and use the term CMS-1500 to locate a form supplier today!

Revised CMS-1500 (08-05) Claim Form
The CMS-1500 form is revised to accommodate the National Provider Identifier (NPI) reporting. When using the revised form it is important to note:

• Field 24J is for Type 1 NPIs (Rendering Provider)
• Field 32a is for Type 2 NPIs (Service Facility)
• Field 33a is for Type 1 or 2 NPIs (Billing Provider)

The above fields are split to allow your current Regence provider number in the shaded area and your NPI in the unshaded area labeled NPI.

New UB-04 claim form accepted March 1, 2007
Regence will begin accepting the new UB-04 (CMS-1400) effective
March 1, 2007. The new form incorporates fields for the National Provider Identifier (NPI), along with other minor form changes.   Either the UB-92 or
UB-04 claim form can be used during the transitional period between
March 1, 2007 and May 22, 2007. Effective May 23, 2007 all paper-submitted institutional claims must use the UB-04.

When using the revised form it is important to note:

• Field 56 is for the NPI of the Billing Facility/Provider
• Field 75 is for Type 1 NPIs (Attending Provider)
• Field 77 is for Type 1 NPIs (Other Referring Provider)

• Claim Filing Procedures
• Guidelines for Timely Submission of Claims
• How to Change Your Address or Tax ID Number
• Coordination of Benefits
• Maintenance of Benefits
• Third Party Liability
• Adjustments

Claim Filing Procedures

Guidelines for Timely Submission of Claims
The following guidelines apply to all types of contracted providers and hospitals across all lines of business including government programs.

• Original claims must be submitted within 12 months from the date of service in order to be processed.
• Any adjustments to the original claim must be submitted within 12 months from the original process date.

NOTE: Non Par Providers, per Medicare guidelines, have 26 months from the date of service to submit a claim for Regence MedAdvantage. Any adjustment to the original claim must be submitted within 12 months from the original process date.

How to Change Your Address or Tax ID Number
In order to enter and process your claims, the Tax ID number and billing address on your claims must match the Tax ID number and billing address on our files. If they do not match our files, the claim will be returned to you requesting updated information or clarification of information contained in our files.

For accurate and timely processing of your claims, please make sure you notify Professional and Provider Relations, in writing, if you make any changes to your billing address or Tax ID number. In order to accurately list your office as a participating provider, it is important to notify Professional and Provider Relations of changes in your practice location as well. If you are changing your Tax ID number, we require that you send us an updated W-9 form. Any of this information may be sent by mail, fax, or e-mail to the following:

Regence BlueCross BlueShield of Utah
Professional and Provider Relations Dept. #26
P.O. Box 30270
Salt Lake City, Utah 84130-0270
 
Fax: (801) 333-6558
 
E-mail: utahprovrel@regence.com

Coordination of Benefits
Coordination of Benefits (COB) is a system that permits your patients to receive benefits from all health insurance plans under which they have coverage while assuring that the total, combined payment from the plans is not more than the total allowed for the service.

When your patient has coverage under two or more insurance plans, one plan is considered the primary plan and “pays first.” The other plan is considered the secondary plan and pays any balances remaining up to its coverage limits. The combined payments provided by the primary and secondary plans cannot be more than the total charges.

The general rule in coordination of benefits is that payment is limited to an amount that, when added to the benefits paid or payable by the other insurer, equals the lesser of:

• 100 percent of the amount the provider has agreed to accept from the primary insurance, or
• 100 percent of the provider’s approved payment amount as determined for Regence BCBSU by the local plan's provider contract.

Maintenance of Benefits
There are some groups that use Maintenance of Benefits (MOB) rules. MOB is a system that permits your patients to receive benefits from all health insurance plans under which they have coverage. It maintains patient responsibility for coinsurance and/or copay amounts on these coverages and assures that the total combined payment from all sources is never more than the total charge for the service(s).

With MOB processing, secondary payers allow benefits only up to their own maximum allowable for the specific service(s). If the primary carrier’s payment is equal to or more than what the secondary carrier’s payment would have been as primary, no additional benefits will be remitted. This can result in members having out-of-pocket expenses, something not usually seen with COB processing.

• Submitting Your Claims

  When your patient has coverage through Regence BSBSU and another coverage plan, you should submit the claim to the primary plan for processing. After the primary payer has processed the claim, the claim should be submitted along with the Explanation of Claims Processed received from the primary plan so that the secondary plan may coordinate with the primary payer.

  If your patient is covered by two group benefit contracts through Regence BCBSU, be sure to list both the group and identification numbers on the claim. We will then process the primary plan first and any remaining balances will be considered for payment under the secondary plan.

• Rules for Determination of Primary and Secondary Carriers

  The first step in coordination is the identification of that program which should pay its benefits first (the “primary” program).

  The primary program is identified through the use of a list of rules. The first rule, which is applicable, identifies the primary program.

  • A program not containing any COB rules is prime.
  • A program covering the spouse as the subscriber is prime to a program covering the spouse as a dependent.
  • A dependent child who is covered by his/her own program is primary to the secondary coverage of the parent.
  • A program not containing these rules, but using the “gender” rule, will determine the COB rule to use.
  • When both parents have programs covering the dependent children and one or both programs use the “gender” rule, the father’s plan will be primary and the mother’s plan will be secondary.
  • When both programs use the “birth date” rule:
    • The coverage belonging to the parent whose birthday (month and day
      only) comes first in the year will be the primary coverage. Do not take into
      account the year of birth.
    • If the parents have the same birth date (month and day), the coverage of the parent who has had his or her coverage longest will be primary. This applies whether or not the dependents have been covered from the original effective date or added recently to either coverage.
  • If two or more programs cover the child as the dependent of divorced or separated parents, benefits for the child are determined in the following order:
    • First, the program of the parent with custody of the child shall be primary to any other dependent coverage. (Unless there is a court decree establishing financial responsibility for the child’s health care expenses to one parent and that parent’s program is aware of the terms
      of such decree, the responsible parent’s program shall be primary to any other dependent coverage.)
    • Second, the program of the child’s stepparent who is married to the child’s custodial parent.
    • Third, the program of the non-custodial parent.
    • Finally, the stepparent who is married to the non-custodial parent.
  • A program covering the patient as an active employee shall be primary to coverage of the patient as a laid-off or retired employee.
  • The program that has covered the patient for the longer period is primary to that which has covered him or her for the shorter time.

Third Party Liability
In order for Regence BCBSU to process claims efficiently and accurately, we need your help.

If you treat one of our members who has been involved in a motor vehicle accident or industrial accident, or was injured at the hand of another, it is important that you submit complete accident information with the claim. Many of our policies have a special accident benefit that may pay at a high rate than the regular policy benefits. For us to process the claims out of the correct benefit, we MUST have the date of onset and the complete accident information. The following are guidelines to help us both.

• No-fault Auto Accidents
  As of July 1, 1974, the No-fault law has been in effect in Utah. The law currently states that anyone residing in the state of Utah for more than 90 days is to have his/her car licensed in Utah and must carry the minimum NO-fault coverage of $3,000 (additional coverage up to $100,000 can be purchased). This law applies to dump trucks, school buses, commuter buses, etc. Any vehicle that is used specifically for intrastate purposes is subject to the No-fault law. Any vehicle licensed in Utah, except 18-wheelers used for interstate travel, must carry No-fault coverage.
  
• No-Fault Coverage
  Utah law states that any claim for injury occurring in, on or around a vehicle is to be filed with the auto carrier and paid out of the No-fault benefit. The following are some examples of claims that should be filed with the auto carrier:
  • Auto/bike or auto/tricycle accidents. This applies whether the vehicle is moving or parked at home in a driveway.
  • Riding a skateboard or inline skating and colliding with an auto.
  • Auto/pedestrian accidents.
  • Hit and run accidents must be filed with the family of the injured person’s No-fault coverage before the health insurance carrier pays.
  • Baby falls out of a car seat or car window.
  • Changing a tire or repairing the car and an injury occurs.
  • Smashed finger in car door.
  • Trailers attached to a vehicle are considered an integral part of the vehicle and subject to No-fault unless they are pared and being used as a residence.

  It is the member’s responsibility to provide us with the PIP (personal injury protection) log from his/her automobile insurer. It is our policy to send a letter to the member asking for this information. As soon as the PIP log is received, all claims that were not paid by No-fault are processed according to contract benefits.

• Workers Compensation
  Any accident that occurs at the workplace, whether during regular hours or after, or at another place while on work business, is considered industrial and should be filed with the industrial carrier. Medical problems that occur as a result of employment are also industrial.

  Examples of industrial cases:

  • Cut finger on file cabinet.
  • Fall down stairs or in parking lot.
  • Cellulitis resulting from a cut or burn at work.
  • Lung ailments caused by breathing caustic fumes or gases.
  • Carpal tunnel or other such repetitive motion injuries
  • Auto accident while delivering packages to the post office or on a delivery route or while on the way to a business meeting.
  • Heart, back, hernia, knee or psychiatric problems directly related to employment.

  All claims that are work related will be denied by Regence BCBSU. If Industrial denies the claim, we need a copy of the denial. We will then reopen the claims and process them according to contract benefits.

• Subrogation
  Subrogation occurs when someone is injured on another person’s property or as the result of another person’s negligence.

  In order to subrogate, the claim must first be paid, per contract benefits, by the health insurance carrier. Therefore, if you submit complete accident information including a date of onset, your claims will be paid per contract benefits. A Subrogation Questionnaire is then sent out to our member asking if someone else was at fault and the attorney’s name or the name of the person with whom they are negotiating. When this information is returned, we contact the attorney or at-fault party and assert our subrogation lien for monies paid out.
  
  Examples of subrogation situations:

• Fall in a store or parking lot.
• Neighbor’s dog or cat bites you.
• Altercations.
• Assaults.
• Motorcycle accidents.
• Off-road vehicle accidents.
• Boating accidents.
• Any injury that is caused through the fault of negligence of someone else.
• Automobile accidents after No-fault is met.
• Workers Compensation accidents when denied and being appealed.

In these cases, all claims are paid per contract benefits. Regence BCBSU then works with the at-fault party to obtain a refund.

As part of your participating provider agreement, you agree to bill the member for only his/her out-of-pocket expenses, incurred as a result of the injury, plus any interest or late fees accrued up to the time of payment.

Payments of the members’ out-of-pocket expenses may be made directly betweenmembers and providers of services. If benefits are provided in the form of service rather than cash payments, the reasonable cash value of each service rendered should be deemed both an allowable expense and a benefit paid.

None of the rules pertaining to coordination of benefits will serve as a barrier to the member first receiving covered services from Regence BCBSU providers.

Adjustments
An adjustment may be made by either Regence BCBSU or the provider when an overpayment or underpayment has been made. This request must be made within 18 months following the date of payment. Adjustments of erroneous payments related to coordination of benefits must be made within 36 months of the erroneous payment. All payments will be final unless an adjustment is requested within the referenced time periods. Adjustment reasons include but are not limited to:

• Duplicate payment
• Payment was sent to wrong provider
• No-fault was involved
• Claim should have been filed with Workers Compensation

When Regence BCBSU identifies an overpayment, a letter will be sent to the provider’s billing office specifically identifying the claim in question, including the member name, member identification number, patient account number, date of service, date paid and amount of the overpayment will also be included. The provider will have 30 days to remit payment. A copy of the overpayment letter must be included with the payment.

If after 45 days, Regence BCBSU has received no response to the overpayment letter, a credit will be taken on a subsequent payment voucher. Automatic credits will also be taken in the following circumstances:

• When the provider identifies an overpayment
• When the provider asks that a credit be taken
• When a corrected billing requiring an adjustment of a claim is received
• When the erroneous payment relates to a Host BlueCard member (patient is a member of a Blue Cross and/or Blue Shield Plan in another state)
• When the erroneous payment is related to a Federal Employee Plan (FEP) member