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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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.

 

Coding Updates

Upcoming Code Edits

Code Editing for Facility High Level Emergency Room Services (Effective March 3, 2023)

Ophthalmology Policies (Effective June 15, 2022)

Gynecologic Screening Services with Preventive Medicine Visits (Effective Nov. 1, 2021)

Revised E&M Codes for Commercial Claims (Jan. 1, 2021)

Durable Medical Equipment and Supplies Policies (Effective June 1, 2021)

Ophthalmology Policies (Effective June 1, 2021)

Maximum Units (MUE) Edits Policy (Effective June 1, 2021)

High-Level Emergency Room Evaluation and Management Services (Effective July 1, 2021)

Insertion of Intrauterine Devices (Effective 9/17/20)

Notice to Facilities Billing Outpatient Services (Effective 7/13/20)

Correct Modifier Reporting and Editing (Effective 4/30/20)

Editing for Procedure/ Revenue Code conflict (Effective 2/1/20)

Diagnosis Code Guideline Policy - ICD-10-CM Sequela (7th character "S") Codes (Effective 2/1/20)

Place of Service Policy - Mutually Exclusive Places of Service (Effective 2/1/20)

Radiation Oncology Policy (Effective 2/1/20)

Diagnosis-Age Policy - Diagnosis-Age Consistency (Effective 12/17/19)

Place of Service Policy - Evaluation and Management Place of Service Restrictions - Part 2 (Effective 12/17/19)

Evaluation and Management Services Policy - Consultation with Annual Exam or Screening Diagnoses (Effective 12/17/19)

Bundled Services Policy - Bundled Services Billed on the Same Day as Other Payable Services (Effective 12/17/19)

Evaluation and Management Services - Outpatient Consultations (Effective 12/1/19)

Genetic Testing - Molecular Pathology Testing for Lynch Syndrome (Effective 12/1/19)

Evaluation and Management - Transitional Care Management (TCM) Services (Effective 12/1/19)

Inappropriate Age for Procedure (Effective 10/1/19)

Pneumococcal Vaccine Frequency (Effective 10/1/19)

Diagnosis Code Guideline Policies (Effective 10/1/19)

Professional Services Billed on CMS 1500 Form (Effective 7/1/19)

Evaluation and Management Services (Effective 7/1/19)

Secondary Diagnosis Coding (Effective 7/1/19)

Appropriate Use of Manifestation Codes Overview (Effective 5/1/19)

Other Updates

Revised E&M Codes for Commercial Claims (Jan. 1, 2021)

 

Lab Testing Code Reimbursement Policies

Avalon Healthcare Solution - Laboratory Procedures Reimbursement Policy

 

BCBST Lab Testing Code Reimbursement Policies

Effective 9/1/2023 through 11/1/2023

Allergen Testing

ANA/ENA Testing

B-Hemolytic Streptococcus Testing

Biochemical Markers of Alzheimer Disease and Dementia

Bone Turnover Markers Testing

Cardiac Biomarkers for Myocardial Infarction

Cardiovascular Disease Risk Assessment

Celiac Disease Testing

Cervical Cancer Screening

Coronavirus Testing in the Outpatient Setting

Diagnosis of Idiopathic Environmental Intolerance

Diagnosis of Vaginitis including Multi-target PCR Testing

Diagnostic Testing of Common Sexually Transmitted Infections

Diagnostic Testing of Influenza

Diagnostic Testing of Iron Homeostasis Metabolism

Epithelial Cell Cytology in Breast Cancer Risk Assessment

Erectile Dysfunction

Evaluation of Dry Eyes Testing

Fecal Analysis in the Diagnosis of Intestinal Dysbiosis and Fecal Microbiota Transplant Testing

Fecal Calprotectin Testing in Adults

Flow Cytometry

Folate Testing

Gamma-Glutamyl Transferase

General Inflammation Testing

Genetic Testing for Adolescent Idiopathic Scoliosis

Helicobacter Pylori Testing

Hemoglobin A1c

Hepatitis C

HIV Genotyping and Phenotyping

Identification of Microorganisms Using Nucleic Acid Probes

Immune Cell Function Assay

Immunohistochemistry

Immunopharmacologic Monitoring of Therapeutic Serum Antibodies

In Vitro Chemoresistance and Chemosensitivity Assays

Intracellular Micronutrient Analysis

Laboratory Testing for the Diagnosis of Inflammatory Bowel Disease

Lyme Disease

Measurement of Thromboxane Metabolites for ASA Resistance

Metabolite Markers of Thiopurines Testing

Nerve Fiber Density Testing

Onychomycosis Testing

Oral Screening Lesion Identification Systems and Genetic Screening

Pancreatic Enzyme Testing for Acute Pancreatitis

Parathyroid Hormone Phosphorus Calcium and Magnesium Testing

Pathogen Panel Testing

Pediatric Preventive Screening

Plasma HIV-1 and HIV-2 RNA Quantification for HIV Infection

Prenatal Screening-Nongenetic

Prescription Medication and Illicit Drug Testing in Outpatient Setting

Prostate Biopsies

Salivary Hormone Testing

Serum Biomarker Testing for Multiple Sclerosis and Related Neurologic Diseases

Serum Testing for Hepatic Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease

Serum Tumor Markers for Malignancies

ST2 Assay for Chronic Heart Failure

Testing For Alpha-1 Antitrypsin Deficiency

Testing for Diagnosis of Active or Latent Tuberculosis

Testing for Mosquito or Tick Related Infections

Testosterone Testing

Thyroid Disease Testing

Urinary Tumor Markers for Bladder Cancer

Urine Culture Testing for Bacteria

Venous and Arterial Thrombosis Risk Testing

Vetra DA Blood Test for Rheumatoid Arthritis

Vitamin B12 Methylmalonic Acid Testing

Vitamin D Testing

Zika Virus Risk Assessment

Effective 11/1/2023

Allergen Testing – G2031

B-Hemolytic Streptococcus Testing - G2159

Biochemical Markers of Alzheimer Disease and Dementia - G2048

Biomarker Testing for Autoimmune Rheumatic Disease - G2022

Biomarkers for Myocardial Infarction and Chronic Heart Failure - G2150

Bone Turnover Markers Testing - G2051

Cardiovascular Disease Risk Assesment - G2050

Celiac Disease Testing - G2043

Cervical Cancer Screening - G2002

Coronavirus Testing in the Outpatient Setting - G2174

Diabetes Mellitus Testing - G2006

Diagnosis of Idiopathic Environmental Intolerance - G2056

Diagnosis of Vaginitis including Multi-target PCR Testing - M2057

Diagnostic Testing of Common Sexually Transmitted Infections - G2157

Diagnostic Testing of Influenza - G2119

Diagnostic Testing of Iron Homeostasis Metabolism - G2011

Epithelial Cell Cytology in Breast Cancer Risk Assessment - G2059

Evaluation of Dry Eyes Testing - G2138

Fecal Analysis in the Diagnosis of Intestinal Dysbiosis and Fecal Microbiota Transplant Testing - G2060

Fecal Calprotectin Testing - G2061

Flow Cytometry - F2019

Folate Testing - G2154

Gamma-Glutamyl Transferase - G2173

General Inflammation Testing - G2155

Helicobacter Pylori Testing - G2044

Hepatitis C Testing - G2036

HIV Genotyping and Phenotyping - M2093

Human Immunodeficiency Virus (HIV) - M2116

Identification of Microorganisms Using Nucleic Acid Probes - M2097

Immune Cell Function Assay - G2098

Immunohistochemistry - P2018

Immunopharmacologic Monitoring of Therapeutic Serum Antibodies - G2105

In Vitro Chemoresistance and Chemosensitivity Assays - G2100

Intracellular Micronutrient Analysis - G2099

Laboratory Testing for the Diagnosis of Inflammatory Bowel Disease - G2121

Lyme Disease Testing - G2143

Measurement of Thromboxane Metabolites for ASA Resistance - G2107

Metabolite Markers for Thiopurines Testing - G2115

Nerve Fiber Density Testing - M2112

Onychomycosis Testing - M2172

Oral Cancer Screening and Testing - G2113

Pancreatic Enzyme Testing for Acute Pancreatitis - G2153

Parathyroid Hormone Phosphorus Calcium and Magnesium Testing - G2164

Pathogen Panel Testing - G2149

Pediatric Preventive Screening - G2042

Prenatal Screening-Nongenetic - G2035

Prescription Meds and Illicit Drug Testing in the Outpatient Setting - T2015

Prostate Biopsies - G2007

Salivary Hormone Testing - G2120

Serum Biomarker Testing for Multiple Sclerosis and Related Neurologic Diseases - G2123

Serum Testing for Hepatic Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease

Serum Tumor Markers for Malignancies - G2124

Testing For Alpha-1 Antitrypsin Deficiency - M2068

Testing for Diagnosis of Active or Latent Tuberculosis - G2063

Testing for Vector-borne Infections - G2158

Testosterone Testing - G2013

Thyroid Disease Testing - G2045

Urinary Tumor Markers for Bladder Cancer - G2125

Urine Culture Testing for Bacteria - G2156

Venous and Arterial Thrombosis Risk Testing - M2041

Vitamin B12 Methylmalonic Acid Testing - G2014

Vitamin D Testing - G2005

Effective 4/1/24

B-Hemolytic Streptococcus Testing - G2159

Biochemical Markers of Alzheimer Disease and Dementia - G2048

Biomarkers for Myocardial Infarction and Chronic Heart Failure - G2150

Bone Turnover Markers Testing - G2051

Celiac Disease Testing - G2043

Cervical Cancer Screening - G2002

Diagnostic Testing of Common Sexually Transmitted Infections - G2157

Diagnostic Testing of Influenza - G2119

Epithelial Cell Cytology in Breast Cancer Risk Assessment - G2059

Fecal Analysis in the Diagnosis of Intestinal Dysbiosis and Fecal Microbiota Transplant Testing - G2060

Fecal Calprotectin Testing - G2061

Hepatitis Testing - G2036

Immune Cell Function Assay - G2098

Immunopharmacologic Monitoring of Therapeutic Serum Antibodies - G2105

In Vitro Chemoresistance and Chemosensitivity Assays - G2100

Laboratory Testing for the Diagnosis of Inflammatory Bowel Disease - G2121

Measurement of Thromboxane Metabolites for ASA Resistance - G2107

Metabolite Markers for Thiopurines Testing - G2115

Nerve Fiber Density Testing - M2112

Prostate Biopsy Specimen Analysis - G2007

Serum Biomarker Testing for Multiple Sclerosis and Related Neurologic Diseases - G2123

Serum Testing for Hepatic Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease - G2110

Testing for Diagnosis of Active or Latent Tuberculosis - G2063

Young female child smiling while being examined with a stethoscope Young female child smiling while being examined with a stethoscope
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.

Reconsideration 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.

Appeals 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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