Our BlueNews Seminars held throughout the state over the last several months generated numerous questions about the Front-End Edit system, Virtual Office and other claims and billing issues. To further the educational process, we begin with this issue of BlueLine a new column devoted to answering your questions.

Q. When batches of claims are submitted electronically and errors are found, is the entire batch rejected or only the specific claims with errors?

A. It depends on which format is submitted and where the editing occurs. We have editing criteria in our EDI Gateway (which is considered our ‘electronic front door’) and additional editing within our front-end edits program that occurs later in the process.

EDI Gateway
For the most part, the editing that occurs at the EDI Gateway has to do with the basic structure of the format — required records are found in the right sequences, fields contain the right type of information (alphabetic or numeric), etc. There are some specific differences based on the type of format submitted, and those differences are mentioned below.

For 1450 NSF institutional claims, we have some claim-level edits at our EDI Gateway. We will accept all claims that pass the edit criteria based on our specifications and return all claims that fail the edit criteria. For example, if 100 claims are submitted, 90 are accepted and 10 are rejected due to edit failure, the 10 claims are returned and must be corrected and resubmitted.

For all other BCBSF or HMO claims, including common format professional, common format institutional and NSF professional claims, the editing that occurs at the EDI Gateway is ‘File Level.’ This means that if there are any errors on the file, the entire file is returned and no claims are accepted. For example, if 100 claims are submitted and there is one error in the file, the entire file (all 100 claims) are returned for correction. Most of the edits at this level deal with the structure of the file, required records, sequencing and balancing. The error(s) must be corrected and the entire file resubmitted.

Front-End Edits Program
Once the claims pass our EDI Gateway, they are routed to our Front-End Edits (FEE) program. At this level, we are looking for claim-specific information and edit on a claim-by-claim basis. For example, if 100 claims are forwarded from the Gateway, 55 claims fail and 45 claims pass, the 45 claims will be forwarded to the appropriate processing systems; the other 55 claims will not pass. We will create a Claims Return Report (CRR) and place it into the submitter’s electronic mailbox. These 55 claims must be corrected and resubmitted.

Q. What if I am unable to get a copy of the Claims Return Report from my vendor or billing service?

A. You must work with your vendor or billing service to obtain these reports. It is critical that you are aware of the failed claims because these claims are not in our system and will not be considered for payment. If your vendor or billing service does not provide this capability, please contact Claims Data Acquisition for other available options at 800-778-6795, Option 2, or email us at: claims.dataacquisition@bcbsfl.com.

Q. Does VO have a target date for checking claim status on out-of-state members?

A. It is possible to check claim status on most out-of-state members today if the out-of-state claim was sent to BCBSF for processing. Enter the member number just as you do today for BCBSF products.

Q. How should we submit a claim for the handling of repeat procedures on the same day for professional component services?

A. Use modifier 26 (professional component) and modifier 76 (repeat procedure, same physician) with the appropriate procedure code. Here’s an example: If a physician performs the professional component (reads, interprets and writes a report) for procedure 71030, chest X-ray, for a patient, and the same procedure is repeated two or more times for the same patient on the same day, here’s how to submit the claim:

• 71030 – 26 on the first line
• 71030 – 76 on the second line
• 71030 – 76 on the third line.

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