COVERAGE & CLAIMS

Find what you need to manage your claims

Our plans provide members with benefits for thousands of services. Confirming your patients' benefits and eligibility before you provide care helps us to process claims efficiently and reimburse you promptly.

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Please visit Availity for member benefits and eligibility information. Click the “Eligibility and Benefits Inquiry” tab on the “Patient Registration” tab at the top of your screen.

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To learn how to file electronic claims, please visit the Electronic Data Interchange (EDI) section on our Digital Resources page.

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You can review claim status through Availity by clicking the “Claim Status & Payments” tab, which is featured on the “Claims and Payments” pulldown at the top of your screen.

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Learn more about our digital resources and how our eBusiness team can help support your electronic business transactions.

CODING INFORMATION

Codes for Submitting Claims

Overview & Definitions

Overview

BlueCross applies code editing rules to evaluate the accuracy and adherence of medical claims to accepted national standards. These rules are based on code editing guidelines such as:

  • National Correct Coding Initiative (NCCI)
  • Centers for Medicare and Medicaid Services (CMS) guidelines
  • American Medical Association (AMA) coding guidelines
  • Guidelines published by medical societies/associations such as:
    • American Academy of Orthopedic Surgeons (AAOS)
    • American College of Obstetricians and Gynecologists (ACOG)
  • BlueCross BlueShield of Tennessee clinical expertise
  • BlueCross code rules are also based on reimbursement policies such as but not limited to the following:
  • Bundled Services Regardless of the Location of Service
    • Bundled Services when the Location of Service is the Physician’s Office
    • Corneal Topography
    • Durable Medical Equipment (Purchase and Rentals)
    • Home Pulse Oximetry
    • Screening Test for Visual Acuity
    • Visual Function Screening
    • Quarterly Reimbursement Changes – These reimbursement policies may be viewed in the Commercial Provider Administration Manual and the BlueCare Tennessee Provider Administration Manual.


BlueCross code editing rules will be applied during the claim payment process. Retrospective audits may still be necessary when all associated claims are available for review.


Code editing can occur on multiple levels depending on the combination of codes reported.


BlueCross reserves the right to request supplemental information (e.g. anesthesia record, operative report, medical records, etc.) to determine appropriate application of code bundling rules.


Final reimbursement determinations are based on several factors, including but not limited to, member eligibility on the date of service, medical appropriateness, code edits, applicable member co-payments, coinsurance, deductibles, benefit plan exclusions/limitations, authorization/referral requirements and medical policy/coverage decisions.


Code edits for BlueCare® and TennCareSelect were implemented March 1, 2014. Further information on these edits may be found on the BlueCare Tennessee website.


CPT® is a registered trademark of the American Medical Association.


Definitions
Comprehensive Code (Column 1)
Generally represents the major procedure or service when reported with another code

Component Code (Column 2)
Generally represents the lesser procedure or service. Reimbursement for a component code is considered included in the reimbursement for the comprehensive code when the service is billed by the same provider for the same patient on the same date of service (i.e., reimbursement for the component code will not be made separately from the comprehensive code).


Retained NCCI
BlueCross edits are based on NCCI logic.


Example: Effective Jan. 1, 2010, the Centers for Medicare and Medicaid Services (CMS) no longer recognize CPT® codes 99241-99245 (office or outpatient consultations) and 99251-99255 (inpatient consultations) under the Medicare Physician’s Fee Schedule.


As a result, CMS termed the edits for these CPT® codes. BlueCross continues to allow providers to bill these consultation codes; therefore, the edits related to these CPT® codes were retained by BlueCross.

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Claims Appeals Policy and Process

Claims Reconsiderations and Appeals

If you disagree with a claims outcome or denial, you can follow these simple steps. Please see our Provider Administration Manuals for additional information by line of business.

STEPS FOR RECONSIDERATIONS AND APPEALS
Request a Reconsideration

If you disagree with a decision we’ve made or if you need to provide additional information that may affect the decision, please submit a Provider Reconsideration Form to us within 18 months of the initial denial. Completion of this step is required before filing a formal appeal.

PDF Icon | BCBS of TennesseeReconsideration Process Map

Appeal the Reconsideration

If you disagree with the reconsideration decision, you may file a formal appeal by submitting a Provider Appeals Form to us. Please see this helpful guide with timelines for each line of business. If the reconsideration stated that the reconsideration decision was related to medical necessity, you may be directed to a separate utilization management appeal form.

PDF Icon | BCBS of TennesseeAppeals Process Map

Request Arbitration

You have the option to request binding arbitration if you’re not satisfied with the formal appeal decision. Please see the Provider Dispute Resolution Procedure or the Provider Administration Manual based on the plan that covers your patient.

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