#Bcbs timely filing for appeals professional

#Bcbs timely filing for appeals professional

Provider shall not bill or collect from a member, or from BCBSOK, charges itemized and distinguished from the professional services provided.billing for services which were not rendered.deliberately billing in a manner which results in a reimbursement greater than what would have been received if the claim was properly filed and/or.deliberate misrepresentation of the services provided to receive payment for a non-covered service.BCBSOK considers fraudulent billing to include, but not be limited to the following:.A Provider is responsible for the actions of staff members or agents. A Provider performing covered services for a Blue Cross and Blue Shield member shall be fully and completely responsible for all statements made on any claim form submitted to BlueCross and Blue Shield of Oklahoma (BCBSOK) by or on behalf of the Provider.Participating providers shall adhere to the following policies with respect to filing claims for covered services to Blue Cross and Blue Shield members: Health Care Fraud Prevention and Reporting Tip Sheet If you have any questions, you may contact our Provider Customer Service Department at 80 to speak with a Customer Advocate for assistance. The EOMB will indicate 'Crossover' or 'XOVER' which tells the physician and/or facility that the claim was submitted to the member's home plan for secondary processing. The physician and/or facility can determine if the claim has been forwarded to the member's home plan by reviewing the Explanation of Medicare Benefits (EOMB). Medicare will process the corrected claim and forward that claim direct to the member's home plan for secondary processing.

Physicians and/or facilities should follow the same process for filing corrected claims for Medicare primary members just as if filing the claim for the first time to Medicare. When physicians and/or facilities see an out of state Medicare primary member, often times that claim is sent directly to the member's home plan for secondary processing by Medicare after primary processing has been completed. BCBSOK has noticed an increase of Medicare primary corrected claims being filed incorrectly to BCBSOK rather than directly to Medicare. By filing the corrected claims to BCBSOK, your claims may be delayed in processing and/or may result in a denial stating the claim either must be filed to Medicare or the claim is a duplicate to the original claim. When physicians and/or facilities find it necessary to file corrected claims on services for a Medicare primary member, the corrected claims should be filed direct to Medicare, not BCBSOK. Preservice and concurrent appeals should continue to be submitted to the member's Home Plan.Are you a provider billing corrected claims on services provided to a Medicare primary member? If you answered 'yes' to this question, BlueCross and BlueShield of Oklahoma (BCBSOK) is here to help you. Please attach any additional information and/or medical records at the time of filing the appeal for consideration. For example, if an Alabama physician provides services to a member with Blue Cross and Blue Shield of Kansas coverage and a post-service appeal is needed, the physician should fill out the appropriate form from above and submit it to Blue Cross and Blue Shield of Alabama. Providers are required to file all post-service appeals to their local Blue Cross Plan regardless of the member's Home Plan. Blue Advantage ® is excluded.įor more information about the appeals process, see the following:

PRO-82 - Utilization Management Appeal Form: To be used for medical necessity appeals (including cosmetic and investigational).

PRO-81 - Professional Reimbursement Appeal Form: To be used for payer allowance and/or incorrect payment or coding rules applied.

PRO-80 - Claims Reconsideration Form: To be used for review of coordination of benefits (COB), coinsurance/deductibles, coverage/benefits, eligibility and/or timely filing.

Please make sure you select the appropriate form to address your specific need. Three forms are also available to aid providers in preparing an appeal request.

The following documentation provides guidance regarding the process for appeals. Blue Cross and Blue Shield of Alabama has an established appeals process for providers and physicians.