Claim Denial: CO55 & PR55 Denials - September 6, 2016
Blue Cross and Blue Shield of Nebraska is dedicated to keeping you informed regarding any system issues or outages that may impact you or your practice.
We have discovered that some CPT codes submitted on the HCFA 1500 claim form are being denied in error as investigational with either a CO55 or PR55 remark code.
- CO55: experimental/investigational; billed charges are provider liability
- PR55: experimental/investigational; billed charges are patient liability
What we are doing to resolve the issue
We are actively working with our claims processing system to identify the source of these denials and to correct the error.
What you can expect
Once we have identified the source of the error, claims that were denied in error as CO55 or PR55 will be reopened and processed.
What to do if you have additional questions or need support
Please continue to submit claims and record denials. We will be running reports to capture affected claims. Services that were denied as PR55 or CO55 IN ERROR will be reopened and processed. NOTE: Claims denied legitimately as investigational will not be adjusted. Only claims denied in error will be corrected. Please call your Provider Relationship Manager (PRM) with any questions.
National Walk at Lunch Day - April 27
Don't forget our 10th annual National Walk at Lunch Day on Wednesday, April 27, 2016! Sign up and take the pledge today!
Tens of thousands of walkers participated nationwide in last year's event and we hope you will help us make this year an even bigger success. Participation is fun and easy.
When done briskly and on a regular basis, walking can:
- Decrease the risk of heart attack and type 2 diabetes
- Control weight
- Improve muscle tone
- Reduce stress
You can make a difference. Blue Cross and Blue Shield of Nebraska will donate $1 per individual or $20 per business/organization or school group registration to Special Olympics Nebraska.
Take the pledge for better health AND a better Nebraska!
Download the Current Version of the Policies & Procedures Manual
The Blue Cross and Blue Shield of Nebraska Policies and Procedures Manual for NEtwork BLUE Health Care Providers/Facilities has been updated and is available for download.
Single Sign on Now Available through NaviNet!
At Blue Cross and Blue Shield of Nebraska, we continue to seek ways to make it easier for providers to deliver the best care to our members.
As part of an update to our NaviNet provider portal, we are happy to introduce a single sign on enhancement that will provide direct, more convenient access to the following vendor program websites:
- Radiology Quality Initiative through American Imaging Management (AIM)
- Spine Pain Management Program through NIA Magellan/RadMD
As part of this new feature, providers can simply log into NaviNet and click on “Spine Pain Management Prior Authorization” and “AIM Diagnostic Imaging Request,” and they will automatically be logged in – no additional user names or passwords needed!
Note: AIM users may have to recreate their favorites within NaviNet’s single sign on account.
Log in to NaviNet today to try the single sign on feature!
Not on NaviNet? Learn more and sign up today!
The advantages of using NaviNet include:
- Check current member claim status – no need to pick up the phone!
- Quickly access member eligibility and benefits information
- Access pre-service review information for out-of-area members.
We understand the workloads you encounter every day and recognize the need for administrative efficiencies. If you have any questions about this new feature or about NaviNet in general, please contact NaviNet at (617) 715-6000.
Providers Are Responsible for Recredentialing
All BCBSNE professional providers are required to undergo recredentialing every three years. The purpose of the recredentialing process is to re-attest a provider’s good standing with state license, valid insurance and other touch points that were required for initial acceptance into the network.
If you or other members of your office staff receive a recredentialing request, do not delay taking the requested action. A lack of response to our recredentialing requests will ultimately result in a provider being terminated from the BCBSNE PPO network.
When a provider’s recredentialing is due, BCBSNE’s online credentialing partner, the Council for Affordable Quality Healthcare (CAQH), notifies the provider that they need to visit CAQH PROVIEW to either complete the online application or update the application and attest it (if the provider has previously completed the CAQH application).
Any communications from CAQH are delegated through BCBSNE. CAQH makes no distinction between initial credentialing and re-credentialing, as monitoring the application completion process is CAQH’s main role. Once the application and/or attestation are complete, CAQH will notify BCBSNE via a weekly roster that the provider has satisfied the application process.
If the provider does not respond to the re-credentialing request after one month, BCBSNE will send a reminder letter. If the request goes unanswered after two months, a third and final certified letter will be sent to the provider advising that they will be terminated from the BCBSNE network if they do not respond within two weeks.
It is important to note that the application is not complete until you have been officially notified by CAQH. For information on the steps and list of items you will need to complete the re-credentialing process, refer to page 3 of the CAQH Universal Provider Datasource’s Quick Reference Guide at bit.ly/10v7u2O
For additional information on BCBSNE’s recredentialing process and helpful tools, visit our Credentialing page, and be sure to review the CAQH credentialing steps within the “How It All Fits Together” section.
Important Information: Anthem Data Breach
Anthem Inc., the country's second-largest health insurance company and a Blue Cross and Blue Shield affiliate operating in 14 states, has reported a data breach that could affect 80 million of its customers and employees.
Personal information was obtained from Anthem's current and former members, including names, birthdays, member identification (ID) and/or Social Security numbers, street addresses, email addresses and employment information, including income data. No medical or financial data (including credit card data) was obtained.
It is important to remember that Blue Cross and Blue Shield of Nebraska is a separate company from Anthem. Based on what we know today, this data breach has not impacted any of BCBSNE's systems. BCBSNE takes particular care to safeguard our members' personal and medical information, and we have extensive data security measures and continuous monitoring in place to deter events such as this.
BCBSNE is working with Anthem to determine the impact on BCBSNE members, and will work together to help those members as more information becomes available. If any BCBSNE members used medical care in one of Anthem's service areas, their information might be compromised. BCBSNE will work with Anthem to notify impacted members in the coming weeks.
Anthem members who may be impacted include members from these plans: Anthem Blue Cross, Anthem Blue Cross and Blue Shield, Blue Cross and Blue Shield of Georgia, Empire Blue Cross and Blue Shield, Amerigroup, Caremore, Unicare, Healthlink, and DeCare. Some of those impacted members may live in Nebraska.
Members with concerns are being encouraged to go to www.anthemfacts.com or call (877) 263-7995 for more information. Anthem is offering free credit monitoring and identity protection services to impacted members.
If you have any questions, please contact your BCBSNE health network consultant.
AIM's 2016 Holiday Schedule
American Imaging Management®, BCBSNE's RQI program administrator, will be closed on the following holidays in 2016:
|Friday, Jan. 1
||New Year's Day
|Monday, Jan. 18
||Martin Luther King Jr. Day
|Monday, May 30
|Monday, July 4
||Independence Day (observed)
|Monday, Sept. 5
|Thursday, Nov. 24
|Friday, Nov. 25
||Day after Thanksgiving
|Monday, Dec. 26
BCBSNE Billing Requirements for Breastfeeding Support, Supplies and Counseling
8/1/2012 Effective August 1, 2012, benefits will be provided for breastfeeding support, supplies and counseling at no cost to the member when obtained from an in-network provider and following the billing and coding guidelines specified below:
Breast Pump Billing Guidelines
- E0602 Breast pump, manual, any type
- E0603 Breast pump, electric (AC and/or DC), any type
- E0604 Breast pump, hospital grade, electric (AC and/or DC), any type
The HCPCS code must be appended with modifier RR or NU to indicate rental versus purchase.
Benefits will be provided for one pump, per pregnancy, at no cost to the member.
Benefits are also available for the following breast pump supplies on a purchase-only basis:
- A4281 Replacement breast pump tubing
- A4282 Replacement breast pump adapter
- A4283 Replacement of breast pump cap
- A4284 Replacement breast pump shield
- A4285 Replacement of breast pump bottle
- A4286 Replacement of breast pump locking ring
Breastfeeding Support and Counseling Billing Guidelines
The following CPT/HCPCS codes are appropriate for lactation support and counseling services provided by an IBCLC: 99211, 99401, 99402, 99403, 99404 or Lactation Classes: S9443, 99411, 99412.
The following CPT codes are appropriate for lactation support and counseling services provided by an MD: 99211, 99401, 99402, 99403, 99404 or Lactation Classes: 99411, 99412.
In order for benefits to be paid at 100 percent, V24.1 must be the primary diagnosis code on the claim. There is no limit in the frequency or number of counseling sessions or classes payable under this benefit.
Note: Lactation services, including breast pumps and supplies, provided to a covered member during an inpatient hospitalization is considered inclusive in the reimbursement made to the hospital and cannot be billed separately.
Individuals who are designated as an International Board Certified Lactation Consultant (IBCLC) are eligible to apply to become a participating provider with BCBSNE, and must meet all credentialing requirements as established and approved by the BCBSNE Credentialing Committee. To apply, complete the Universal Application and Practitioner Authorization forms. A Provider Agreement may be requested from HealthNetworkRequests@nebraskablue.com.
IBCLCs who are a salaried employee of a hospital or home health agency are still required to be credentialed by BCBSNE and file claims under their own name and individual NPI number.
Questions regarding credentialing should be sent to CredentialingRequests@nebraskablue.com.
Guidelines for Anesthesia Services Provided by CRNAs Employed by a Hospital
3/11/2010 Effective immediately CRNAs who are an employee of a hospital will need to obtain an NPI and advise BCBSNE of their NPI for claim filing. NPI notification forms are available online. In addition to needing their individual NPI, we need their date of birth and social security number. Once we have received this information, we will update our provider files.
Services provided by a CRNA who is an employee of a hospital must adhere to the following billing guidelines:
- Anesthesia claims must be billed with minutes not units
- Never put the surgeon’s NPI number on the claim
- Do not write start and stop times on the claim
Paper claims guidelines:
- Box 24J must include the CRNA’s individual NPI
- Box 31 must include Prof Serv CRNA with the CRNA’s first and last names underneath Prof Services CRNA
- No punctuation
- Prof Serv CRNA
- Smith Jane CRNA
- Box 33A must include the entity’s NPI number
Electronic claim guidelines:
- The 2310B Loop (Rendering) should include the CRNA’s name and individual NPI
- The 2010AA Loop (Billing) should include the billing entity’s name and organizational NPI