System Conversion Claims Handling

Purpose

This policy establishes the requirements and process for handling claims affected by a provider system conversion and defines when limited timely filing exceptions may be considered.

Advance Notification Requirement

• Advance notice is required. Providers must submit the Provider Attestation as soon as they know a system conversion may affect billing, coding, or claim submission. The attestation must be submitted at least 30 days before the conversion or go-live date.
  • The notice must include the conversion or go-live date, the scope of operational impact, and the anticipated disruption period.
  • Notice provided less than 30-days before the conversion or go-live date may not qualify under this policy unless an exception is approved in advance by BCBSNE.
  • Upon receipt of the notification, BCBSNE will review the request and notify the provider whether the notice satisfies the requirements of this policy and whether timely filing requirements will be waived
  • If the system conversion is delayed, disrupted, or does not go as planned, providers must notify BCBSNE as soon as possible, but no later than 10 calendar days after becoming aware of the issue. BCBSNE will review the circumstances internally and determine whether the approved timeline will be extended.
• Failure to provide advance notice. If a provider does not notify BCBSNE before the system conversion, this policy will not apply, and timely filing denials will not be eligible for review under this process.
• Pre-submission contact is required for untimely claims. If claims are already beyond standard timely filing limits, providers must contact BCBSNE before submitting those claims for review and direction.
• Provider attestation supports review. The provider attestation and any required supporting documentation will be used to review the system conversion impact and determine whether claim submission instructions or temporary timely filing edit suppression may apply.
• Providers remain responsible for timely submission. Providers must continue to use good faith efforts to submit claims within standard filing limits whenever possible, even when a system conversion has occurred.

Timely Filing Exception Framework

• Claims within the 60-day grace period. BCBSNE may allow up to 60 additional days after the provider’s normal timely filing deadline when the provider:
  
  • BCBSNE advance notice;
  • Meets the requirements of this policy; and
  • Submits affected claims within five calendar days after BCBSNE advises the provider that the claims are cleared for submission
• Claims outside the 60-day grace period. Claims are not eligible for this process when:
  
  • The claim is submitted after the approved 60-day grace period; or
  • The provider does not meet this policy’s requirements

In these cases, timely filing denials will be upheld, and the claims will remain the provider’s responsibility. Providers remain contractually responsible for submitting the claims so BCBSNE can process them and document the denial.

Circumstances That Place Claims at Risk

Claims are at risk when a provider does any of the following:

• Provides notice after the system conversion has occurred
• Submits untimely claims without first contacting BCBSNE
• Misses the approved submission window
• Submits documentation that does not support the claimed system conversion impact

Applicability. This policy may not apply to all lines of business and does not apply to Medicare Advantage claims. ASO business and non-Nebraska members may also be excluded at the discretion of the applicable plan.   

General claim review requirements. Meeting the requirements of this policy does not override standard claim review. All claims remain subject to eligibility, benefits, medical policy, billing and coding review.

Threshold Dollar Amount. Anticipated claims that are above $50,000 in billed charges may be subject to additional review. Advanced notification of high-cost services is required.