Posted on 02-19-2015
IMPORTANT CHANGES EFFECTIVE APRIL 20, 2015: PROVIDER ASSIGNMENT OF LIABILITY
PROVIDER RESPONSIBILITY IDENTIFIED
On January 1, 2014 the Committee on Operating Rules for Information Exchange (CORE®) in conjunction with the Blue Cross Blue Shield Association (BCBSA), as part of administrative simplification, mandated (Phase III) Operating Rules for Electronic Funds Transfer & Electronic Remittance Advice (EFT & ERA). Within the Phase III operating rule set is CORE 360 Uniform Use of Claim Adjustment Reason Codes and Remittance Advice Remark Codes (835) Rule, which defines business scenarios and allows code combinations for use on the ERA transaction (835). These business rules identify which party is responsible for non-covered services: providers or members.
Highmark Blue Cross Blue Shield West Virginia (Highmark West Virginia) will be implementing this update April 20, 2015. What this means to you is that some previous member liability (rejections) will now become provider liability, as follows:
• Maximum number of days authorized have been exceeded.
• Authorization was approved for an observation stay only, when inpatient stay occurred.
• Required pre-certification/pre-authorization is not on file.
This implementation will apply to BlueCard members you are seeing today. In the past, if an authorization was not obtained for a BlueCard (out of area) member, the member was assigned liability and providers could bill the patients.
Beginning April 20, 2015, providers will not be able to bill the out of area patients for services rejected for above reasons. Providers should work with their staff submitting authorizations to ensure they are obtaining authorizations for both BlueCard and Highmark West Virginia members.
To assist with appropriate authorization requests Highmark West Virginia encourages providers to use NaviNet®. It’s convenient, accurate, and timely in meeting all your authorization request needs.