Reimbursement News

State Health Plan High Option Claims Submission Requirements The following information is required for submitting electronic and/or hardcopy claims for services provided to State Health Benefit Plan indemnity High Option Members by the following health care providers: nurse practitioners, certified nurse midwives, certified registered nurse anesthetist, physician assistants and physician assistant anesthetists. Current ICD-9 diagnosis codes, HCPCS and CPT-4 procedure codes. (There should be only one procedure code per line and codes should be listed to the fifth digit. HCPCS and CPT-4 procedure codes should include modifiers where applicable.) Complete all fields and submit on standard pre-printed HCFA-1500 form. The following are examples of significant data elements: Place of service Procedure and diagnosis codes Modifier code, if applicable (e.g. surgical assistant) Submission of provider name and Tax ID information Nurse Practitioners, CRNAs and Nurse Midwives: Submit your name along with your individual tax ID or the tax ID for your designee (e.g. group practice) Physician Assistants and Physician Assistant Anesthetist: Submit your name long with the tax ID of your sponsoring/supervising physician. Dates of Service Time Spent administering anesthesia, if applicable Complete accurate member and insurance information including Alpha prefix of 'S' (only on electronic claims) before the member's ID number Correct spelling of the member's name Date of birth and sex of member Relationship between member and primary insured Additional information for submitting claims to BCBSGA: Use the S prefix in front of the member ID number for State Health Benefit Plan claims when filing electronic claims. Include actual CPT-4 code only once for each claim line and V-codes for well care. Submit therapy charges with the number of units equal to the number of days these services were rendered and not the number of modalities per service. Check formatting and print quality of hard-copy claims before submission. Misaligned data elements and light print may prevent your claims from being processed. To avoid problems send original red HCFA 1500 forms rather than copies. Include primary payment information with coordination of benefits (COB) claims submitted for secondary payment. NOTE: Part B Medicare claims are automatically crossed over from Medicare to the BCBSGA State system where Medicare is primary. Obtain required pre-authorizations. Verify eligibility and benefit limits before rendering services. Rubber-stamp the type of claim (e.g., adjustment, corrected bill, tracer, etc.) on the face of hard-copy bills to ensure correct identification. Do not use red ink when stamping, because the scanning equipment may not be able to read this information. Corrected bills are those where a remittance advice has already been received by the provider. Check the back of the member's insurance card for the correct mailing address for hard-copy claim submissions. The following are common reasons for rejected claims (i.e., claims that cannot be processed): Outdated, incomplete, or non-specific ICD-9, HCPCS and/or CPT codes on the claim Incomplete data elements Invalid or incorrect contract information (i.e., member number) Member ineligible for BCBSGA coverage Illegible hard-copy claims Inappropriate submission of surgical assistant services by the sponsoring/supervising MD Direct submission of services by mid-level providers for other than the SHBP indemnity account (with the exception of CRNAs, which are currently allowed to bill direct) Note: Rejected hard-copy claims will be mailed back to the sender along with a request for additional information that is necessary to process the claim. The following is a type of claim that should not be submitted electronically: HCFA-1500 Claims with late charges The following are tips for resubmitting claims: Please verify that the claim has not been received by BCBSGA and do not resubmit claims until at least thirty (30) calendar days have passed from the original date of submission. Resubmitted claims will be denied as duplicates when the original claim has already been received by BCBSGA unless changes have been made and the new claim is identified as an adjusted/corrected claim, Corrected bills are those claims for which the provider has already received a remittance advice. Mailing Address for Submitting Hard Copy Claims State Health Benefit Plan P.O. Box 38151 Atlanta, GA 30334 Verification of Eligibility & Claim Status Inquiries Verification of a State Health Benefit Plan High Option member's eligibility and benefits can be made via the telephone Voice Response Unit (VRU). The following information is required to verify a member's eligibility and benefits and/or to inquire on the status of a submitted claim: Member's Name Member's ID Number Member's date of birth Date of service (required for claims status inquiries only) Charges submitted (required for claims status inquiries only) State Health Benefit Plan Telephone Numbers Service    Telephone Number    Hours of Operation Eligibility & Benefits 800-653-7041 7:00 am - 10:00 pm    Atlanta Area 404-656-7041 7:00 am - 10:00 pm Claims Status Inquiry 800-626-6402 7:00 am - 6:00 pm    Atlanta Area 404-262-7191 7:00 am - 6:00 pm Electronic Data Interchange EDI Service Institutional is responsible for development, marketing, sales installation, training and support of Electronic Claims Systems. EDI Service Institutional offers a system (Manage Care) that provides claim submission and claim status and eligibility for our private business, Medicare A and Georgia Medicaid. Please call 1-800-638-9677 for product support or information regarding electronic solutions. EDI Services Vendor Division is responsible for the set up and support of vendors and vendor sites relative to electronic claim submission. EDI Services Vendor Division supplies electronic specifications and works closely with vendors during the initial setup, testing phase and provides ongoing support for both the vendor and their respective sites. EDI Services educates providers on electronic claim reports and are available to help with any questions they may have. Vendor support calls and general questions should be directed to the support line at 1-888-883-2720.

Reimbursement Guide (Adobe PDF Format) - A Guide to Reimbursement for Georgia Physician Assistants , prepared by the members of the GAPA Reimbursement Committee. Reimbursement Feedback Are you having a problem with reimbursement for physician services provided by PAs? Would you like the assistance of the GAPA reimbursement team? Or, do you have a success story on PA reimbursement that you would like to share with GAPA? Online Reimbursement Feedback Form - This form will be emailed to us. Fax/Mail Reimbursement Feedback Form - If you prefer to print, fill out and fax/mail your feedback in, use this form. Adobe PDF files may only be viewed with Adobe's Acrobat Reader. The Reader is a free download. Click on the icon to download the Reader from the Adobe web site.