Claims Filing Information

Claims may be filed either electronically or on paper for Blue Cross & Blue Shield of Rhode Island plan members and out-of-state Blue Cross & Blue Shield plan members. For paper claims submissions, use the CMS-1500 form. We accept the 08/05 version of the form. You may download the CMS-1500 (08-05) Informational Guide to learn how to complete Blue Cross’ mandatory fields on the claim form. For general inquiries on all other fields, please visit the National Uniform Claim Committee website.

A claim must be submitted for all services not included in a capitation compensation arrangement. Claims for non-capitated services provided by personal physicians will be considered for payment of allowable fees and accumulation of utilization data related to ambulatory services.

When the rendered services are included in a personal physician’s capitation arrangement, a data-only claim is submitted. These claims are called encounter claims. All mandatory elements on a CMS-1500 form must be completed for encounters, including box 10A, which identifies work-relatedness. Encounter data helps us evaluate network and physician-specific utilization of ambulatory services, and is an important aspect of our quality improvement program.

All claims must be submitted within 180 days of the date of service.
 

Electronic Claims Submission

Studies have shown that providers can see a substantial savings by submitting claims electronically. Statistics also show that claims submitted to Blue Cross electronically and in a HIPAA-compliant format adjudicate faster because they meet our clean claim specifications more often. Blue Cross is dedicated to servicing our providers in their efforts to submit electronically and in a HIPAA-compliant format. If your practice is interested in converting your systems, and wishes to move from paper to electronic claims submission, visit our HIPAA section.
 

Services Requiring Claims Submission
The following are examples of typical professional services that require claims submission:

  • All office evaluation/management services, including new and established patient office visits, new and established patient preventive visits, and office consultations
  • Surgical services
  • Hospital visits and inpatient consultations
  • Lab work, x-rays, and EKGs
     

Required Information

To ensure prompt payment, complete all mandatory fields on the claim form including, but not limited to:

  • Personal information that identifies the member as a subscriber or dependent of a subscriber, and other pertinent data
  • Coverage information, including the member’s specific plan; coverage from other carriers; and any information that can help identify whether another party is financially liable for the charges
  • Identifying rendering physician/provider information
  • Identifying referral physician/provider information, if appropriate
  • Charge of the service
  • Patient treatment information, including diagnosis, CPT®, or HCPCS code for the service and any applicable modifier(s), date services were rendered, and service site
  • Tax identification number (TIN)

When the required information is not included, the claim will be denied. A new claim with correct and complete information must be submitted in order for a denied claim to be reconsidered. A Claim Adjustment Request Form can be completed and submitted with a corrected claim.
 

Clean Claims Defined

A clean claim for payment of healthcare services is one that is submitted via acceptable claim forms or electronic formats with all required fields completed with accurate and complete information in accordance with the insurer’s requirements.

A claim is considered “clean” if the following conditions are met:

  1. The services must be eligible, provided by an eligible provider, and provided to a person covered by the insurer.
  2. The claim has no material defect or impropriety, including, but not limited to, any lack of required substantiating documentation or incorrect coding.
  3. There is no dispute regarding the amount claimed.
  4. The payer has no reason to believe that the claim was submitted fraudulently or there is no material misrepresentation.
  5. The claim does not require special treatment or review that would prevent the timely payment of the claim.
  6. The claim does not require coordination of benefits, subrogation, or other third-party liability.
  7. Services must be incurred during a time where the premium is not delinquent. (This condition does not apply to BlueCHiP for Medicare members.)

If you have questions about whether or not your claims meet all conditions of a “clean claim,” you may contact the Physician and Provider Service Center at (401) 274-4848 or 1-800-230-9050.
 

Claim Filing Procedures

To file a claim:

  1. Complete a CMS-1500 claim form.
  2. Submit the form to:

Blue Cross & Blue Shield of Rhode Island
500 Exchange Street
Providence, RI 02903

To be considered for benefit payment, you must submit a clean claim within 180 days of the date of service or completion of an inpatient stay, or monthly in the case of an extended stay. Although not submitted for payment purposes, encounter claims must also be received within the same timeframe. Claims submitted after the time limit will be denied. Please remember that in accordance with your participating physician/provider agreement, you may not “balance bill” patients for services that were denied because you did not meet timely filing requirements.
 

Payment Errors

Blue Cross has the right to recover from physicians/providers any payments made in error. In turn, physicians/providers have the right to have payment determinations reconsidered and adjustments made when appropriate.

We routinely conduct random retrospective audits of claims payments. We look for errors that physicians/providers may have made on claim forms or errors made by Blue Cross in verifying authorizations, claim system data entry, or payment processing.

If Blue Cross has over-compensated a provider in error for services rendered, we have the right to recover the overpayment amount by offsetting against future settlements.

If a retrospective audit reveals that Blue Cross has not compensated a physician/provider in full for services rendered, a payment adjustment will be made automatically. If you have received payment from the member and we later reimburse you for the service, you must reimburse the member what he or she paid.

Overpayment recoveries and underpayment adjustments will be itemized on the physician’s/provider’s next settlement. All over/underpayment adjustments are reflected in the physician’s/provider’s annual utilization and compensation experience.

CPT® is a trademark of the American Medical Association.

CMS-1500 (08-05) Informational Guide