Claim Filing Information INSIDE THIS ISSUE: FEP Point-of-Service identification numbers

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1 May 30, 2000 INSIDE THIS ISSUE: CLAIMS FILING INFORMATION Pages 1-4 FEP Point-Of-Service Identification Numbers Guidelines For Newborn Care Claims Mailing Address for Claims and Customer Service Inquiries Assistant Surgery Denial List Addition Total Parenteral Nutrition Therapy Guidelines Republished Claim Denial Procedure Reminder BOEING TRADITIONAL MEDICAL PLAN Page 5 HME Certificates Of Medical Necessity IV Therapy Claims Boeing Traditional Medical Plan Phone Numbers ATTACHMENTS 2000 Physical Medicine Modality & Procedure Guidelines Update QUESTIONS: If you have questions, please contact your Professional Relations Representative, or the Professional Relations Hotline at , or in the Topeka area, OUR WEB ADDRESS: ACKNOWLEDGEMENT: CPT five-digit codes, nomenclature and other data are copyright 1999 American Medical Association. All Rights Reserved. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein. The Blue Shield Report is Published by your Professional Relations Department Claim Filing Information FEP Point-of-Service identification numbers When completing claims for FEP Point-of-Service (POS) insureds and dependents, please be sure to use the R plus the 8 digits of the insured's identification number. Example: R digits only, not 10. Do NOT include the last 2 digits (i.e., 01, 02), as they are NOT part of the identification number. If you submit 10 digits, this creates problems with claims submission and delays processing as well as claims payment. Sent to: CAP

2 Blue Shield Report Newsletter May 30, 2000 Page 2 Guidelines For Newborn Care Claims As a reminder, BCBSKS guidelines for newborn care claims consider to be a five-day inclusive code. Therefore, procedure codes and will be content of service when billed with Hospital discharge day management, 30 minutes or less History and examination of the normal newborn infant, initiation of diagnostic and treatment programs and preparation of hospital records. (This code should also be used for birthing room deliveries.) Subsequent hospital care, for the evaluation and management of a normal newborn, per day Sending Claims and Customer Service Inquiries Paper claims and customer service inquiries should no longer be sent to the Wichita office. Rather, they should be sent to the Topeka office at: Blue Cross and Blue Shield of Kansas PO Box 239 Topeka, KS As in the past, correspondence for the Professional Relations Representatives or Medical Review staff in the Wichita office may continue to be sent using either of the Wichita addresses below: Blue Cross and Blue Shield of Kansas 257 N. Broadway Wichita, KS Physical Medicine Modality And Procedure Guidelines Attached for your reference, you will find the Blue Cross and Blue Shield of Kansas 2000 Physical Medicine Modality and Procedure Guidelines. The number of units allowed per day has been changed for procedure codes 97033, 97035, and Please replace the guidelines that were distributed December 29, 1999, in Blue Shield Report S with this updated document.

3 Blue Shield Report Newsletter May 30, 2000 Page 3 Assistant At Surgery Denial List It has recently been determined that an assistant at surgery is not required for 35400, Angioscopy (non-coronary vessels or grafts) during therapeutic intervention. Your Business Procedure Manual will be updated to reflect this information. Total Parenteral Nutrition (TPN) Therapy Guidelines The indications for use of total parenteral nutrition therapy are being republished at this time to include a reminder regarding information to be included when requesting prior authorization for patients whose primary diagnoses are not among those listed. Daily parenteral nutrition is considered reasonable and necessary for patients with severe pathology of the alimentary tract and for whom regular oral feeding is impossible and alimentation is the only source of nutrition. Hospitalization for Total Parenteral Nutrition (TPN) is not required to initiate IV parenteral nutrition. INDICATIONS FOR USE OF TOTAL PARENTERAL NUTRITION: Short bowel syndrome Intestinal obstruction from carcinomatosis Inflammatory bowel syndrome Motility disorder (pseudo-obstruction) Radiation enteritis Mesenteric infarction Massive bowel resection Diagnosis of hyperemesis gravidarum Patients whose diseases are amenable to treatment and all attempts at enteral nutrition have been unsuccessful or are not feasible and, INITIALLY, TPN supplements at least 80% of the patient's calories. Predetermination requests for coverage of total parenteral nutrition therapy may be submitted for patients whose primary diagnoses are not among those listed and for whom normal oral feeding is impossible. For prior authorization, please include the following information: 1) Is oral feeding impossible? 2) Is TPN the only source of nutrition? 3) Has enteral feeding been tried? a) If yes, why did it fail? b) If no, why not? 4) If the patient can eat, a) What is the patient's expected caloric intake? b) What calories is TPN going to provide? 5) Amount of TPN on a daily basis and indicate when or if there has been any change. 6) If non-contracting, do you accept Kansas allowances?

4 Blue Shield Report Newsletter May 30, 2000 Page 4 Claim Denial Procedure Reminder When processing claims, we find that additional information from the provider is sometimes necessary to complete the claim. Some examples are: the claim may be missing information, the claim may have conflicting information, a review of the medical records may be necessary, or an invalid procedure or diagnosis code may have been submitted on the claim. If a service on a claim cannot be processed due to lacking or incorrect information, that line of service is suspended and a remark code provided. Some examples of these remark codes are listed below. R04 R10 RF0 RG3 RLD Additional information is required to complete processing of this service. To obtain this information, we have mailed an inquiry to the provider of service or to the patient, as appropriate. Processing has been suspended awaiting the requested information. We have insufficient information to complete processing of this service as the HCPCS/CPT/CDT code is invalid or missing. Processing has been suspended awaiting the correct code. We have insufficient information to complete processing of this service as the HCPCS/CPT/CDT code is invalid or missing. Processing has been suspended awaiting the correct code. We have insufficient information to complete processing of this service as the diagnosis code is invalid or missing. Processing has been suspended awaiting the correct code. Please resubmit using the appropriate evaluation and management code. The other lines of service on the claim that do not need additional information are suspended with the new denial code RMV. RMV This service is denied awaiting information regarding another service billed on the same claim form. The suspended claim is returned to the provider. If there are codes that would be bundled during processing, the claim is returned to the provider with a Remittance Advice showing the bundling completed. REFILING THE SUSPENDED CLAIM To receive proper payment, make the necessary corrections and refile the entire claim. If some of the codes were bundled during the original processing, do NOT re-file the claim with BOTH the original codes AND the bundled codes. Resubmit the claim with the codes originally filed, keeping in mind the bundling process will occur again. When the claim is resubmitted, it is input into our system as a NEW claim with a new claim identification number. The original claim will remain in our claims system to reflect the original processing disposition. For additional information, refer to newsletter S dated September 14, 1999.

5 Blue Shield Report Newsletter May 30, 2000 Page 5 Boeing Traditional Medical Plan Please note the following Boeing information pertains only to those Boeing insureds who have the Traditional Medical Plan coverage; it does not apply to the Boeing Premier Blue group. HME Certificates of Medical Necessity In Blue Shield Report S-34-99, December 8, 1999, we informed you that Regence requires a Certificate of Medical Necessity (CMN) to be filed with every HME claim. Then we asked you to fax the CMN to Regence Blue Shield at because BCBSKS does not have the technology to electronically transmit the CMN with the claim. Reminders: To be sure your HME claims are processed quickly and accurately, you should include on the CMN the patient's name and identification number as well as other pertinent information. For orthotic and prosthetic devices, a copy of the physician's prescription can be faxed to Regence in lieu of the CMN. IV Therapy claims Regence Blue Shield of Seattle, Washington, does not require a CMN form for the infusion pump for IV therapy. However, the infusion pump must be pre-authorized. The information required for pre-authorization can be faxed to Regence at: Boeing Traditional Medical Plan phone numbers For inquiries regarding Boeing Traditional Medical Plan (administered through the BlueCard Program): Membership, Eligibility, Benefits Precertification Claim Inquiries Toll-Free Toll-Free , ext Toll-Free Topeka-Area NOTE: For inquiries regarding Boeing Premier Blue (BCBSKS), call: Toll-free Topeka area