Happening Now

Copayment Discrepancy

Updated July 9, 2019

For members whose plan has migrated to our new system Health Rules, we have identified a communication gap regarding the copayment displaying in Navinet. The copayment information displaying is not accurate. For copayment amounts, the member should refer to their benefits or contact Customer Service.

Providers should use IVR or can call Customer Service to obtain accurate copayment amounts for those plans on HealthRules. To know which plans have migrated, please refer to the plan code on the ID card.

Plan Codes
The plan code on the front of the ID card will change when the plan has moved to HealthRules.
Current Plan Code: 263/763
New Plan Code: 259/759

Please be sure to enter the correct ID number from the members card as the ID numbers have changed once migrated.


Updated May 31, 2019

You will notice changes to the recoupment initiation notifications and recoupment offsets displayed in your 835s and EOPs. Changes include the following:

Changes to 835 and EOP:
  • Recoupment offsets will be reflected immediately
  • Recoupment offsets will not happen for a minimum of 30 days after notification
  • When money is deducted from a future payment; it will be important to reference the previous 835/EOP for details
  • Once a claim has been adjusted/voided, the adjustment/void and the offsetting of the recoupment will be reflected in the next 835 and/or EOP
New for HealthRules:
  • FEP claims will offset immediately
  • Partial recoupments
  • dental recoupments
  • Payment Impact = True
    • The financial impact is realized on this RA
  • Payment Impact = False
    • The financial impact is realized on future RA
  • Reversals will no longer be seen on the recoupment claim run since this was communicated when the recoupment was initiated
  • The received payment amount will only reflect in the 835 when claims have been adjusted and the payment is applied to the receivable within the same payment cycle.
  • On the paper remit (EOP) when a recoupment is offset against from a subsequent payment run you will see a recoupment amount listed next to the corresponding claim number as well as the total recoupments and the net payment
  • When the receivable is reported on the current payment is recouped against itself in the same payment, the final claim will include an extract message representing the change in payment amount but not recoupment details
  • The claim being voided will reflect as a reversal of the original 835 that was generated for that claim payment
  • That void will appear as the exact opposite of the original 835
    • Each line amount and count will be shown with the opposite amounts (positives will become negatives and negatives will become positives)
    • Since there will be no net change in the check payment, the net reversal to the paid amount will also be reflected in a check level Provider Adjustment (PLB) segment with a qualifier of Forwarding Balance (FB) for a negative adjustment
Guide to Understanding the Adjustments
Notes include:
  • Where to find the adjustments on the claim
  • An example of the new change where positives become negatives and negatives become positives
  • How to tell if the adjustment affects the claim
  • An example of a message indicating the amount retracted from the adjusted claim

Questions? Reach out to your Provider Executive Team »

Claims System Transition

April 1, 2019

At the beginning of the year, we began transitioning to a new claims processing system, called HealthRules. HealthRules provides a next generation core administration system for health plans which allows for improved efficiencies in administration.

The transition started with FEP CareFirst and BCBSNE employees plan on January 1, 2019. Other members will be transitioned in stages. Throughout this transition, our goal is to minimize disruption to our customers. The following are some of the changes that our members and providers will notice.

Member ID Cards

New ID cards will be provided for members with updated information, such as a new prefix, ID number and customer service telephone number. Members must provide their new card to their doctor, pharmacy or facility.

new member ID card

Plan Codes
The plan code on the front of the ID card will change when the plan has moved to HealthRules.
Current Plan Code: 263/763
New Plan Code: 259/759
HealthRules will offset Dental Claims. FEP will take immediate offsetting for CareFirst and other FEP claims.
Payment Cycles
Please see below for updated payment cycles.

Plan Code Payment

Claims Review and Remittance Advice (RA)

Claims for BCBSNE employees and retires (with prefixes NEQ and YZL) on 1/1/19 or after are being reviewed to ensure quality processing. We are sending remits and applicable payments in small increments and expect to be sending higher volumes in the upcoming weeks.

Some terminology and documents are changing. Remittance Advice (RA) has new formats and fields as well.
Remittance Advice Tip Sheet