|
Frequently Asked Questions — Providers:
Arkansas Blue Cross and Blue Shield Plans
General
- How do I file a claim?
- How do I mail a claim?
- How long does it take a claim to process?
- After a claim is processed, who receives the payment?
- How do I ask for a re-review of a claim?
- Who do I contact with questions about claim status or benefits?
- Who do I contact with questions about the Remittance Advice (RA)?
- What do I do if I need to make corrections on a claim?
- What do I do when I receive a refund request letter?
- How do providers get Advanced Health Information Network (AHIN)?
Medical Benefits
- Do you cover gastric bypass or organ transplant?
- What is the difference between precertification and pre-notification? When is it needed?
- What requires prior authorization?
- Do you cover a newborn back to date of birth on individual policies?
- What is BlueCard®?
For any other questions, please call the Customer Service number found on the back of your ID card.
General
1. How do I file a claim?
Claims can be filed manually or electronically. For any assistance, call your Network Development Representatives.
top
2. How do I mail a claim?
Mail a completed Claim Form, along with the attached itemized bills, to:
Arkansas Blue Cross and Blue Shield
P.O. Box 2181
Little Rock AR 72203-2181
top
3. How long does it take to process a claim?
If the claim does not require any additional requests for information or review it can take 3-5 days
for processing. A claim can take longer depending on the requested information.
top
4. After a claim is processed, who receives the payment?
If the provider accepts assignment, this means the provider will not balance bill and Arkansas Blue Cross and Blue Shield
will make payment and give claim information directly to the provider. Payment for claims involving providers who do not
accept assignment is sent to the policyholder and not the provider.
top
5. How do I ask for a re-review of a claim?
Anytime a provider disagrees with the denial of a code or the payment level of a code on a claim, the provider should
submit a request for reconsideration to the re-review team in the Medical Audit and Review Services division. Please
write Claim Re-review (MARS) on the letter or the envelope. The re-reviews can be faxed to: 501-378-3282. It is only
after the re-review team upholds the denial or level of payment that it would be appropriate to appeal the denial or
payment level to the Appeals Coordinator.
top
6. Who do I contact with questions about claim status or benefits?
For assistance, call the customer service at 1-800-238-8379. If you would like to receive 24/7 access to patients’
benefits and medical claims and much more, register with Advanced Health Information Network (AHIN). For any
assistance, call your network development representative or the AHIN Customer Support staff at 501-378-2336.
top
7. Who do I contact with questions about the Remittance Advice (RA)?
For assistance with claim inquiries, contact customer service at 1-800-238-8379.
top
8. What do I do if I need to make corrections on a claim?
The Arkansas Blue Cross definition of a corrected claim is a claim that has been processed, whether paid or
denied, and was refiled with additional charges, a different diagnosis, or any information that would change the
way that claim was originally processed. Placing the "Corrected Claim" indication on the claim form when it has
not been previously processed will cause a delay in claim adjudication.
Claims returned to the provider requesting additional information should NOT be refiled as corrected claims. These
claims have been processed; however, additional information is needed to finalize payment. Inappropriate usage of the
Corrected Claim form will result in information being returned to the provider.
Do not use the Corrected Claim form for the following:
-
New Claims
-
Appeals
-
Medical Records
-
Invoices
-
Inquiries
-
Adjustments
For a Corrected Claim form, click on the following link: Forms for Providers.
To file corrected claims electronically, reference the Provider Manual online.
top
9. What do I do when I receive a refund request letter?
While all parties strive for accurate claim adjudication on the first pass, occasionally adjudication mistakes are detected
that result in the need to adjust the amount paid. When the adjustment results in a reduction of the claim payment amount,
Arkansas Blue Cross and Blue Shield sends the provider notice of any overpayments through a refund request letter, as well
as on the remittance advice (RA) in the section called “Adjustments”. The notice contains patient and claim information
including the patient account number for ease of tracking.
While Arkansas Blue Cross request refunds within 30 days from the date of the letter or RA, Arkansas Blue Cross prefers
that providers allow recovery of the overpayment from a future remittance if the provider agrees with the overpayment
determination. This will take place after the 30-day period assuming the provider has claims payments to cover any, or
all, of the overpaid amount. This requires less administrative work for the provider and Arkansas Blue Cross.
In order to ‘close’ patient accounts more timely, providers may return the letter with the notation “Recoup Immediately”,
and Arkansas Blue Cross will initiate the recovery within approximately 10 days assuming the provider has claims payments
to cover any, or all, of the overpaid amount. If the provider does not have claim payments sufficient to cover the
overpayment during a 90-day period, Arkansas Blue Cross will send a follow-up requesting a check for the overpaid amount.
Please note: If Arkansas Blue Cross must offset to recoup duplicate or erroneous payments (overpayments) made to
providers, providers are not allowed to pursue collection of such offset amounts from the members against whose claims
such offsets are made.
top
10. How do providers get Advanced Health Information Network (AHIN)?
AHIN access is free of charge. To gain access to the system, complete the following:
-
Download the AHIN Setup Document and Agreements (96 KB PDF)
-
Complete, sign and mail the documents to:
Advanced Health Information Network
601 S. Gaines Street
P.O. Box 1489
Little Rock, Arkansas 72203-1489
An AHIN Customer Support Representative will notify the contact person listed on the AHIN setup document when all
testing is complete and provide the assigned usernames and password.
For questions regarding the AHIN documents, contact the local Network Development Representative or call AHIN Customer Support at 501-378-2336.
top
Medical Benefits
1. Do you cover gastric bypass or organ transplant?
Gastric bypass and organ transplant except for cornea kidney transplant procedures require prior approval. Prior
Approval is a request from a physician for the approval of a proposed hospitalization, a surgical procedure or a
medical treatment. To obtain prior approval, send provider's written request to:
Arkansas Blue Cross and Blue Shield
Attn: Medical Audit and Review
PO Box 2181
Little Rock, AR 72203-2181
Fax: 501-378-6647
top
2. What is the difference between precertification and pre-notification? When is it needed?
Preadmission certification or precertification is a process where a member must call and receive prior approval for an
admission into any hospital. Failure to receive preadmission certification usually involves a penalty payment by the
member of a specified dollar amount – varies by plan design. Arkansas Blue Cross and Blue Shield no longer requires
preadmission certification.
Pre-notification is a process where a member should call in prior to admission to an out-of-network hospital facility or a
hospital outside the state of Arkansas to alert us of the admission. Pre-notification provides information helping to
determine if case management would be an appropriate option for the member.
Pre-notification is not required for outpatient treatment or any in-state, in-network inpatient admissions.
If the inpatient admission does not fall within the described exceptions previously mentioned, the policy may require
pre-notification. You or the patient would need to contact Integrated Health, the Arkansas Blue Cross and Blue Shield
pre-notification vender, by calling 1-800-451-7302.
top
3. What requires prior authorization?
Prior authorization is a review prior to the time a specified procedure is scheduled. This review consists of checking
clinical documentation to verify the medical necessity for the procedure. The review is done by National Imaging
Associates (NIA) and New Directions based on medical guidelines from Arkansas Blue Cross and Blue Shield. A prior
authorization is required for each different procedure, even if those procedures are performed on the same day. Failure
to obtain prior authorization will result in denial of the claim.
Procedures requiring prior authorization:
NIA — Specified high tech radiology procedures, MRI's, CT's, PET scans, and nuclear cardiology, must have prior
authorization. Inpatient services, emergency room services and observation room services are not subject to this review.
New Directions (Still applies if insurance is secondary payor) —
-
Inpatient stays
-
Emergency admission (next business day)
-
Partial hospitalization program
-
Intensive outpatient program
-
Prior to 9th outpatient visit
For any assistance, call the customer service at 1-800-238-8379. Provider calls from Texarkana inquiring about the
need for prior authorization should call 1-877-642-0722.
top
4. Do you cover a newborn back to date of birth on individual policies?
If the policy is a Comprehensive Blue PPO, an HSA Blue PPO II or any other Individually Owned policy and the Plan Type
is Individual/Spouse or Individual/Children AND if the request is received within 90 days of the newborn’s date of
birth or date of adoption, the newborn will be added back to the date of birth without medical underwriting.
However, if the policy is a Comprehensive Blue PPO or an HSA Blue PPO II and the request is not received within
90 days of the newborn’s date of birth or date of adoption, the addition is subject to medical underwriting and the
coverage will be effective on the next possible monthly billing cycle following approval.
top
5. What is BlueCard®?
BlueCard is a national program that allows
providers to see members of other Blue Cross Blue Shield plans, but allows them to file claims and be serviced through
their Blue Cross Blue Shield plan.
top
|