Government Programs: Electronic Claim-related Process Improvements and Reminders

The notice applies to providers submitting claims transactions for Blue Cross and Blue Shield of Texas (BCBSTX) government programs for Blue Cross Medicare Advantage (HMO)^SM, Blue Cross Medicare Advantage (PPO)^SM, Blue Cross Medicare Advantage (HMO-POS)^SM, Medicaid STAR, STAR Kids and CHIP lines of business.

Providers submitting electronic government programs claims for Medicare Advantage and Texas Medicaid members may have experienced membership validation claim rejections and duplicate claim rejections. The duplicate claim rejections occurred when Professional and Institutional electronic claims (837P and 837I transactions) were resubmitted within 90 days of a previously submitted claim that included the exact data for the same patient and date(s) of service.

Effective Sept. 15, 2018, BCBSTX will implement claim processing changes that will eliminate the above referenced claim submission rejections for government programs members. With this implementation, some providers may encounter new claim submission edits for Professional and Institutional claims (837P and 837I transactions), which will improve accuracy and timeliness in processing. Claims with insufficient or invalid data will reject upon claim submission; allowing providers to correct the error(s) and resubmit the claim immediately thereby avoiding claim processing delays. Additionally, electronic claims submitted by 5 p.m. (CT), submitters should receive the payer acknowledgement response files on the same day.

As a reminder, electronic claims that are submitted via the Availity^® Provider Portal or Experian^TM Health must be submitted using Payer ID 66001 for Texas Medicaid (STAR, STAR Kids, CHIP) and 66006 for Medicare Advantage claims. For claims that are submitted using direct data entry on the Availity Portal, providers should select the drop-down payer option of “BCBSTX Medicaid STAR Kids” or “BCBSTX Medicaid STAR/CHIP” for Texas Medicaid claims and “Blue Cross Medicare Advantage” for Medicare Advantage claims.

Providers who are not registered with Availity or Experian Health should contact their clearinghouses to confirm the appropriate Payer IDs to be used when submitting government programs claims, as other clearinghouses may assign their own unique numbers.

These changes will not impact electronic fund transfer (EFT) or electronic remittance advice (ERA).

Please share this notice with your practice management/hospital information system software vendor, billing service or clearinghouse, if applicable. If you have questions regarding an electronic claim rejection message, contact your practice management system software vendor, billing service or clearinghouse for assistance. For additional information on electronic options, refer to the Electronic Commerce page located in the Claims & Eligibility section of our website at bcbstx.com/provider.

Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSTX.

Experian Health is an independent third-party vendor and is solely responsible for its products and services.

BCBSTX makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Availity and Experian Health. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly.