After the examination

• You will return to the recovery area. 

• You will need to rest for about 45 minutes as you have had sedation. Once recovered you may eat and drink as normal. 

• After the procedure you may still have a little wind but this will pass naturally. 

• Before you go home the nurse will explain the results to you and any further treatment that is necessary. Any biopsy result will take longer. 

• A letter will be sent to your GP. 

Going home 

If you have had sedation: 

• you must have a friend or relative to take you home and stay with you for at least 24 hours;

• you must not drive, drink alcohol, operate machinery (including the oven and kettle), or sign important documents, for 24 hours following the test; 

• if you have had Entonox you cannot drive for 30 minutes after the last dose of medication; 

• you may notice that your bowels do not return to normal for a few days following the procedure; 

• you may have a mild sore throat, but this will pass and is nothing to worry about. If you did not have sedation the restrictions above do not apply.

Are there any significant risks?

This test is very safe, but there are some risks associated with this procedure. 

These include: 

• a reaction to the sedative. The sedative can affect the breathing, making it more slow and shallow;

• damage to crowned teeth or dental bridgework; 

• fever (raised temperature); 

• there is a slightly increased risk of developing a chest infection after a gastroscopy procedure; 

• when a biopsy is taken or a polyp is removed, rarely there may be a little bleeding. (Risk approximately one for every 100 to 200 examinations where a polyp is removed). If this does not stop within 24 hours or is excessive, please contact the Endoscopy Unit or Accident and Emergency; 

• perforation which is a little tear in the wall of the bowel, this is also rare. (Risk approximately one for every 1000 examinations). This would require a short stay in hospital and treatment with antibiotics, or, very occasionally, may require surgical repair.

Please talk to your endoscopist before your examination if you have any worries about these risks.

On arrival at hospital

• Please report to the reception of the Endoscopy Unit. 

• A nurse will check your details, blood pressure and pulse. If you are allergic to anything (medication, plasters, latex) please tell the nurse. 

• You will be asked to remove any jewellery, false teeth, spectacles, contact lenses and tongue studs before the examination. 

• Please inform the nurse if you have a pacemaker, replacement joints, pins or plates. 

• You will need to change into a hospital gown. 

• Please do not hesitate to ask any questions you may have. 

• You will have the test you will be undergoing explained to you during your admission. You will then be asked to sign a consent form. 

• A nurse will stay with you throughout the examination..

What does the examination involve? 

• You will have sedation. 

• A small needle will be inserted into a vein and a sedative and/or painkiller injected before starting the examination. This will make you feel relaxed but rarely induces sleep.(This will be left in lightly strapped to your hand/arm until you are recovered from the procedure). 

• For some patients we offer the use of Entonox for this procedure or no medication at all. Entonox is the pain relief gas that women receive while giving birth. It works by taking in a deep breath using a mouth piece.  

• Very occasionally, at the patients request, the endoscopist agrees the procedure can be carried out without sedation. Please discuss this with the endoscopist.

• The nurse or endoscopist will discuss with you whether you will have a local anaesthetic spray (numbing) on the back of your throat; this has a bitter taste.

• A small device for recording the pulse and breathing will be attached to your finger. You will be given oxygen. 

• A cuff will be placed on your arm to monitor your blood pressure. (Please inform the nurse if there is a reason why a certain arm cannot be used). 

• A small mouthpiece will be placed in your mouth. 

• The endoscopist will gently insert the gastroscope into your stomach. This is not painful and will not make breathing or swallowing difficult, but you may feel like retching and feel uncomfortable during the test. 

• The stomach will be gently inflated with air to expand it so that the lining can be seen more clearly. The air is sucked out at the end of the test. 

• The nurse may need to clear saliva from your mouth using a small suction tube.

• Afterwards the gastroscope is removed easily and the trolley is turned around. 

• A rectal examination will be performed by the endoscopist before the colonoscopy procedure.

• Then while you are comfortably lying on your left side the endoscopist will gently insert the colonoscope into your back passage and pass it around the whole of the large bowel. 

• Air will be passed into the bowel to expand it so the bowel lining can be seen more clearly. This  may give you some discomfort, but it will not last long. 

• You may need to pass wind during your procedure this is normal and the endoscopist is used to it. Please do not be embarrassed. 

• A biopsy (a small sample of the lining of your bowel) may be taken during the examination to be sent to the laboratory for more tests. You cannot feel this. (A video recording and/or photographs may be taken for your records). 

• Similarly, any polyps may be removed during the examination, but you will not feel this either.

 • Polyps are small growths in the lining of the bowel; they are not cancerous but could turn into a cancer in years to come if not removed. Polyps are removed by cutting them out. 

• This is done by placing a small loop of wire through which a low current of electricity is passed, causing the stem to be burnt through. Afterwards the colonoscope is removed easily

Endoscopy

We perform colonoscopy and upper GI endoscopy at Glens Falls Hospital, Saratoga Hospital, and Northern GI Endoscopy located at Five Irongate Center, Glens Falls. Please read the following instructions pertaining to the appropriate location of your procedure

Glens Falls Hospital: The Glens Falls scheduling staff will be calling to pre-register you. If you have not been contacted within 10 days of your scheduled appointment please call 926-5327. You will need to complete the Glens Falls Hospital Pre-Admission History and Physical form and bring it with you to the GI Center on the day of your procedure. You can print out this form by going into patient forms and click on Glens Falls Hospital Admission History and Physical. On the day of your exam, please report directly to the GI Center 45 minutes prior to the time of your exam, located past the emergency room entrance on the left (east) side of the hospital around to the back of the hospital. The parking lot for the GI Center is located on the back (south) side of the hospital immediately adjacent to the entrance of the GI Center. 

Saratoga Hospital: Please call the Registration Desk at 587-3222 on any weekday before your scheduled exam to pre-register. On the day of your exam, please report directly to the 2nd floor Day Surgery/Endoscopy area one hour prior to your appointment. Enter to the right side of the hospital (ground level, Same Day Surgery, Ambulatory entrance). 

Northern GI Endoscopy: You will be contacted by a staff member of Northern G.I. Endoscopy prior to your procedure to confirm your appointment and answer any questions that you may have. You will need to complete the Northern GI Endoscopy Pre-Admission History form and bring it with you to Northern GI Endoscopy on the day of your procedure. You can print out this form by going into patient forms and click on Northern GI Endoscopy Pre-Admission History Form. On the day of your exam, please report to Northern G.I. Endoscopy, located directly behind our office at 5 Irongate Center in Glens Falls, one hour prior to the time of your exam. There are designated parking spaces for Northern GI patients along the side of the building, near the Pine Street entrance.

Member Cost-sharing- Coinsurnace, copay

Deductibles, coinsurance and copayments are the member’s contribution toward all services. As a participating provider, you have agreed to not waive these amounts. When the charge for an office visit is less than the member’s copayment, providers should collect the actual charge. If you collect any amount above the copayment for covered services, you must refund the member the excess amount collected within 30 days of notification of the overpayment.

Participating providers have also pledged to assist us in our efforts to keep our members’ costs down. Please be aware that members could pay higher copayments for certain covered services performed by different types of providers and facilities. The chart below illustrates an example situation of how a member’s cost share will increase if they go to an outpatient facility for services that may be performed at an in-network physician’s office, in-network independent lab or free-standing diagnostic imaging facility:

Reimbursement Review

Blue Cross recognizes there may be times when participating providers disagree with the way a claim was adjudicated.

In those instances, providers may complete the Claims Dispute Form included in this manual. Our new Claims Dispute Form has replaced the Reimbursement Review Form. This form is available online now for use for when you have a claims dispute.

Effective June 1, 2016, we no longer accept the Reimbursement Review Form. Please be sure to complete the entire form and include any supporting documentation. Please return the form to Customer Service, P.O. Box 98029, Baton Rouge, LA 70898-9029.


Family Members Excluded

REMINDER: Any services rendered by a provider to a family member such as a spouse, child, stepchild, parent, stepparent or grandparent, etc. are excluded as services you may bill to Blue Cross.

EDI - Exchange , clearing house. ERA

Electronic Transaction Exchange

Various healthcare transactions can be submitted electronically to the Blue Cross clearinghouse in a system-to-system arrangement. Blue Cross does not charge a fee for electronic transactions; however, the trading partner is responsible for its own expenses incurred for sending and/or receiving electronic communications.

You can send your transactions to Blue Cross via indirect submission through a clearinghouse or through direct submission to the Blue Cross EDI Clearinghouse. For more information about system-to-system electronic transactions, please contact EDI at EDICH@ bcbsla.com or 225-291-4334.

Administrative Representative

Blue Cross and Blue Shield of Louisiana now offers network providers the option to request inpatient and outpatient authorizations electronically through our iLinkBLUE Provider Suite. In 2016, network providers will be required to manage their behavioral health and/or Blue Advantage (as applicable) services electronically. It is necessary to have a designated Administrative Representative before you can access many of the new portals (including the authorizations portals) that are being added to iLinkBLUE.

The role of an administrative representative is to serve as the key person at your organization who will:
• Delegate electronic access to appropriate users.
• Ensure those appropriate users adhere to our guidelines.
• Only grant access to those employees who legitimately must have access in order to fulfill their job responsibilities.
• Promptly terminate employee access at such time as an employee changes roles or terminates employment with the organization.
If your facility does not have a designated administrative representative, please contact our Provider Relations department at provider.relations@bcbsla.com or 1-800-716-2299, option 4.

Electronic Payment Register/Remittance Advice (HIPAA 835 Transaction)

Providers, who submit their claims electronically, can receive an electronic file containing their Weekly Provider Remittance Advice/Payment Register. Once downloaded at the provider’s office, the remittance file can be uploaded into an automated posting system, thus eliminating a number of manual procedures. The ERA is available Monday mornings, allowing providers to begin posting payments as soon as possible.

ERA specifications are available from Blue Cross at no cost to vendors and providers, but they  do require programming changes by your practice management billing system vendor. Traditionally, there is an up-front fee from your vendor for programming. From that point, you may receive the Blue Cross weekly Remittance Advice/Payment Register at no charge. For more information, please contact Blue Cross EDI at EDICH@bcbsla.com or 225-291-4334.

EDI - Insurance eligibility verification

Electronic Data Interchange (EDI)

Providers can decrease paperwork and increase operating efficiency with Electronic Data Interchange (EDI). EDI is the fastest, most efficient way to exchange eligibility information, payment information and claims. Blue Cross’ experienced EDI staff is ready to assist in determining the best electronic solution for your needs.

iLinkBLUE Provider Suite

iLinkBLUE Provider Suite is a free provider tool that allows providers to verify members’ eligibility, coinsurance and deductible information, file claims electronically, check claims status, and more from an Internet connection. iLinkBLUE features more than 30 applications and allows
providers to have immediate access to Blue Cross member, claims and authorization data from any Internet-ready desktop using Internet Explorer version 8 or higher. iLinkblue users can:

• Verify eligibility and benefit coverage.
• Verify dollar amounts remaining for deductible and out-of-pocket expenses. (This information is updated daily).
• Electronically submit CMS-1500 and UB-04 claims for Louisiana members, FEP members and out-of-state members.
• Submit and receive pre-authorizations for Imaging Authorizations.
• Submit claim inquiries electronically using our “Action Request” functionality.
• Review outstanding Medical Record Requests for out of area members.
• Obtain status of paid, rejected and pending claims and authorization verification.
• View and print current accepted/not accepted claims reports.
• View and print Payment Registers and Electronic Funds Transfer information on Monday of each week.
• View allowable charges online.
• Access various manuals, BlueCard out of area network information, and medical policy guidelines.
• Check the iLinkBLUE message board often for added features, news and important notices.

Follow-up on Crossover Claims

Blue Cross Blue Shield of Louisiana:

• Wait 21 days before conducting follow-up on iLinkBLUE Blue Cross Blue Shield out-of-state plans:

• Wait 30 days before contacting the out-of-state plan Services Excluded or Not Covered by Medicare When a charge is considered excluded or not covered, providers are not required to wait the 31 days to file the claim. The claim should contain a GY modifier with the specific, appropriate, HCPCS code, if available. If there is not a specific HCPCS code, a “not otherwise classified code” (NOC) must be used with the GY modifier.

These claims can be filed electronically or on paper to Blue Cross and Blue Shield of Louisiana.

Medicare Payment Rules for Consultation Services

Medicare no longer recognizes consultation CPT codes 99241-99245 and 99251-99255. This applies for both Medicare-primary and Medicare-secondary claims. Please Note: These codes are still valid CPT codes for 2010, and Blue Cross continues to accept these

consultation codes. We have current allowable charges for these codes and any changes in allowable amounts or billing policies for these codes will be communicated to our providers with a 90-day notice. At this time, we do not anticipate any changes.

Per CMS, physicians and others must bill an appropriate Evaluation and Management code for the services previously paid using the consultation codes. If the primary payer for the service continues to recognize consultation codes, physicians and others billing for these services may either:
1. Bill the primary payer an Evaluation and Management code that is appropriate for the service, and then report the amount actually paid by the primary payer, along with the same Evaluation and Management code, to Medicare for determination of whether a payment is due; or

2. Bill the primary payer using a consultation code that is appropriate for the service, and then report the amount actually paid by the primary payer, along with an Evaluation and Management code that is appropriate for the service, to Medicare for determination of whether a payment is due.
Note: The first option may be easier from a billing and claims processing perspective.

For more on this from the CMS, go to
www.cms.hhs.gov/MLNMattersArticles/downloads/MM6740.pdf and www.cms.hhs.gov/MLNMattersArticles/downloads/SE1010.pdf.
If you have any questions or require additional information on Medicare supplemental claims, please contact Provider Services at 1-800-922-8866.

Medicare Part A Benefit Exhaust Claims Requirements

Blue Cross requires the following when Medicare Part A benefits exhaust:

• Medicare exhaust letter, including the date Medicare benefits exhausted. Medicare Part A charges and Explanation of Benefits (EOB) must match.
• Blue Cross authorization from the date Medicare benefits exhausts.
• Medicare EOB for the entire stay.
• When Medicare has exhausted for the entire stay, one (1) claim needs to be submitted with admit date to discharge date inclusive of all Part A charges.
• When Medicare exhaust in the middle of the stay, two (2) claims should be submitted with one claim representing all services from the admit to the exhaust date and another claim listing the exhaust date to discharge date.
If you have questions, please email Network.Administration@bcbsla.com.

iLinkBlue 1500 Claim Electronic Entry Screen

Block 1 Type(s) of Health Insurance - Indicate coverage applicable to this claim by checking the appropriate block(s).

Block 1A Insured’s I.D. Number - Enter the member’s Blue Cross and Blue Shield identification number, including their three-character alpha prefix, exactly as it appears on the identification card.
Block 2 Patient’s Name - Enter the full name of the individual treated.

Block 3 Patient’s Birth Date - Indicate the month, day and year. Sex - Place an X in the appropriate block.

Block 4 Insured’s Name - Enter the name from the identification card except when the insured and the patient are the same; then the word “same” may be entered.

Block 5 Patient’s Address - Enter the patient’s complete, current mailing address and phone number.
Block 6 Patient’s Relationship to Insured - Place an X in the appropriate block. Self - Patient is the member.

Block 6 Spouse - Patient is the member’s spouse. Child - Patient is either a child under age 19 or a full-time student who is unmarried and under age 25 (includes stepchildren). Other - Patient is the member’s grandchild, adult-sponsored dependent or of relationship not covered previously.

Block 7 Insured’s Address - Enter the complete address; street, city, state and zip code of the policyholder. If the patient’s address and the insured’s address are the same, enter “same” in this field.

Block 8 Reserved for NUCC USE - This section is reserved for NUCC use. Deleted “Patient Status” and content of field.

Block 9 Other Insured’s Name - If the patient has other health insurance, enter the name of the policyholder, name and address of the insurance company and policy number (if known).
Block 10 Is patient’s condition related to: a. Employment (current or previous)?; b. Auto Accident?; c. Other Accident?. Check appropriate block if applicable.


Block 11 Not required.

Block 11D When appropriate, enter an X in the correct box. If marked “YES”, complete 9, 9A and 9D.
Only one box can be marked.

Block 12 Patient’s or Authorized Person’s Signature - Appropriate signature in this section authorizes the release of any medical or other information necessary to process the claim. Signature or “Signature on File” and date required. “Signature on File” indicates that the signature of the patient is contained in the provider’s records.

Block 13 Insured’s or Authorized Person’s Signature - Payment for covered services is made directly to participating providers. However, you have the option of collecting for office services from members who do not have a copayment benefit and having the payments sent to
the patients. To receive payment for office services when the copayment benefit is not applicable,

Block 13 must be completed. Acceptable language is:

a. Signature in block d. Benefits assigned
b. Signature on file e. Assigned
c. On file f. Pay provider

Please Note: Assignment language in other areas of the CMS-1500 claim form or on any attachment is not recognized. If this block is left blank, payment for office services will be sent to the patient. Completion of this block is not necessary for other places of treatment.


Block 14 Date of Current - Enter the first date of illness, injury or pregnancy filed on claim- Enter the 6-digit (MM/DD/YY) or 8-digit (MM/DD/YYYY) date of the first date of the present illness, injury, or pregnancy. for pregnancy, use the date of the last menstrual period (LMP) as the first date.
Block 15 Enter another date related to the patient’s condition or treatment. Enter the date in the 6-digit (MM/DD/YY) or 8-digit  (MM/DD/YYYY) format. Enter the applicable qualifier to identify which date is being reported.

Block 16 Dates Patient Unable to Work in Current Occupation - Enter dates, if applicable.


Block 17 Name of Referring Provider or Other Source - Enter the name ( First Name, Middle Initial, Last Name) followed by the credentials of the professional who referred or ordered the service(s) or supply(ies) on the claim. If multiple providers are involved, enter one provider
using the following priority order:
1. Referring Provider
2. Ordering Provider
3. Supervising Provider
Do not use periods or commas. A hyphen can be used for hyphenated names. Enter the qualifier to the left of the vertical, dotted line.
Block 17A Other ID#. The non-NPI ID number of the referring physician, when listed in Block 17.
Block 17B NPI – Required. Enter the national provider identifier (NPI) for the referring physician, when listed in Block 17.
Block 18 For Services Related to Hospitalization - Enter dates of admission to and discharge from hospital.
Block 19 (Designated by NUCC) - Additional Claim information to be completed by NUCC.
Block 20 Laboratory Work Performed Outside Your Office - Enter, if applicable.
Block 21 Diagnosis or Nature of Illness or Injury- Enter the applicable ICD indicator to identify which version of ICD codes is being reported: “9” for- ICD-9-CM or “0” for ICD-10-CM codes- Note: All transactions, electronic or paper-based, for services on and after October,
1, 2015, must contain ICD-10 codes or they will be rejected. Blue Cross will not accept ICD- 9 codes with dates of services on or after October 1, 2015. Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. Enter the codes to
identify the patient’s diagnosis and/or condition. List no more than 12 ICD-9-CM or ICD-10- CM diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. Do not provide narrative description in this field.
 Block 23 Prior Authorization Number- Enter the authorization number obtained from Blue Cross/ HMO Louisiana, if applicable.

Block 24A Date(s) of Service - Enter the “from” and “to” date(s) for service(s) rendered.

Block 24B Place of Service - Enter the appropriate place of service code. Common place of service codes are:

Inpatient - 21 Outpatient - 22 Office - 11

Block 24C EMG - Enter the Type of Service code that represents the services rendered.
Block 24D Procedures, Services, or Supplies - Enter the appropriate CPT or HCPCS code. Please ensure your office is using the most current CPT and HCPCS codes and that you update your codes annually. Append modifiers to the CPT and HCPCS codes, when appropriate.
Block 24E Diagnosis Pointer - Enter the diagnosis code reference letter (pointer) as listed in Block 21 to relate the date of service and the procedures performed to the primary diagnosis.
When multiple services are performed, the primary reference letter for each service should be listed first, other applicable services should follow. The reference letter(s) should be A-L or multiple letters as applicable. ICD-10-CM diagnosis codes must be entered in Block 21 only. Do not enter them in 24E.

Block 24F Charges - Enter the total charge for each service rendered. You should bill your usual charge to Blue Cross regardless of our allowable charges.

Block 24G Days or Units - Indicate the number of times the procedure was performed, unless the code description accounts for multiple units, or the number of visits the line item charge represents. Base units value should never be entered in the “units” field of the claim form.
Block 24J Rendering Provider ID# - Enter the national provider identifier (NPI) for the rendering physician for each procedure code listed when billing for multiple physicians’ services on the same claim. Laboratory, Durable Medical Equipment, Emergency Room Physicians,
Diagnostic Radiology Center, Laboratory and Diagnostic Services, and Urgent Care Center providers do not have to enter a physician NPI in this block. Please enter the facility NPI in blocks 32A and 33A as instructed.
*Rural health clinics and Federally Qualified Health Centers are required to enter the rendering provider NPI.

Block 24K Expand claim line to report NDC, Quanitity, and Measurement.

Block 25 Federal Tax I.D. Number - Enter the provider’s/clinic’s federal tax identification number to which payment should be reported to the Internal Revenue Service.

Block 26 Patient’s Account Number - Enter the patient account number in this field. As many as nine characters may be entered to identify records used by the provider. The patient account number will appear on the Provider Payment Register/Remittance Advice only if it
is indicated on the claim form.

Block 27 Accept Assignment - Not applicable - Used for government claims only.
Block 28 Total Charge - Total of all charges in Item F.
Block 29 Amount Paid - Not required.
Block 30 Not required.
Block 31 Signature of Provider - Provider’s signature required, including degrees and credentials.
Block 32 Name and Address of Facility - Required, if services were provided at a facility other than the physician’s office.
Block 32A NPI - Enter the NPI for the facility listed in Block 32.
Block 32B Other ID. The non-NPI number of the facility refers to the payer-assigned unique identifier of the facility.
Block 33 Billing Provider Info & Ph# - Enter complete name, address, telephone number for the billing provider.
Block 33A NPI - Enter the NPI for the billing provider listed in Block 33.
Block 33B Other ID#. The non-NPI number of the billing provider refers to the payer-assigned unique identifier of the professional.

Medicare Supplemental Claims

In order to reduce the administrative expense and time involved with manual claims submission, in most cases, Medicare supplemental claims will automatically cross over to Blue Cross and you do not need to file a claim for the Blue Cross portion to be processed.

For out-of-state BCBS members

Blue Plans may receive crossover claims for providers who are not within their state boundaries. All claims for out-of-state Blue Plan members will be processed by the out-of-state Blue Plan listed on the member’s ID card.

Provider information at Medicare and Blue Cross of Louisiana

To further ensure eligible Medicare Supplemental claims cross over from Medicare to Blue Cross successfully, please notify us immediately of the following:

• If you have a new Tax ID number, or
• If you have not previously given Blue Cross your NPI, you must do before filing claims including your NPI. For instructions, see the National Provider Identifier section of this manual.

How to determine if the claim was crossed over from Medicare

If a claim is crossed over, you will receive a message beneath the patient’s claim information on the Payment Register/Remittance Advice that indicates the claim was forwarded to the carrier.

Example 1: “Claim information forwarded to: BCBS of Louisiana-Supplemental
Example 2: “Claim information forwarded to: BCBS of Alabama

When a Medicare claim has crossed over, providers are to wait 30 calendar days from the Medicare remittance date before submitting a claim to Blue Cross and Blue Shield of Louisiana. Claims you submit to the Medicare intermediary will be crossed over to Blue Cross only after they have been processed by Medicare. This process may take approximately 14 business days to occur. As a result, upon receipt of the remittance advice from Medicare, it may take up to 30 additional calendar days from the crossover for you to recieive payment or instructions from Blue Cross.

If the remittance does not contain a message similar to the above, the claim was not crossed over to the payer. This claim must be filed on paper to the Plan listed on the member’s ID card. The following claims are excluded from the crossover process for Blue Cross:

• Original Medicare claims paid at 100 percent
• 100 percent denied claims with no additional beneficiary liability
• Adjustment claims that are non-monetary/statistical
• Medicare Secondary Payer (MSP); claims for which other insurance exists for beneficiary
• National Council for Prescription Drug Programs (NCPDP) claims

What to do when the claim WAS NOT crossed over from Medicare  For Louisiana claims that did not crossover automatically (except for Statutory Exclusions), the provider should wait 31 days from the date shown on the Medicare remittance to resubmit the claim. Claims submitted before 31 days will be rejected on the Blue Cross and Blue Shield of Louisiana Not Accepted Report.

After 31 days, the claim that did not crossover can be submitted electronically in the 837 format (if  ending through a clearinghouse, verify your clearinghouse allows the electronic submission of these claims) or on a paper claim form (CMS-1500 or UB-04) along with a copy of the Medicare remittance advice.

Employment-related Injuries or Illness

There are generally three types of legal remedies available to members who sustain employment-related injuries or illnesses:

• Workers’ Compensation under state law – Workers’ Compensation under state law is a legal remedy whereby an employee who is injured within the course and scope of employment is usually entitled to certain benefits regardless of whether anyone was at fault.

• Longshore & Harbor Workers’ Compensation Act (LHWCA) - The LHWCA is a federal law that provides for the payment of medical care to employees who suffer “on the job” injuries that occur on the navigable waters of the United States or in adjoining areas used in loading, unloading, repairing or building certain vessels, regardless of whether anyone was at fault.

• Jones Act – The Jones Act is a federal law that provides protection only to “seamen” who are injured while working on a vessel.

Please understand that we do not make any coverage determinations as to which legal remedy would apply to a member’s injury.

We understand that it can be very difficult to determine which one of these legal remedies may cover a particular injury or illness; however, your patients may have medical benefits available to them under their Blue Cross contract. All claims for covered services, including those claims for which a third party may be liable, must be filed directly to Blue Cross. Please understand that services for injuries and illnesses that arise under the Jones Act, like any other covered services that do not fall under any workers’ compensation guideline, are not considered contractual exclusions, and therefore, must be filed with Blue Cross. Although services that fall under a workers’ compensation guideline are, in most circumstances, typically excluded under the terms of the member contracts/certificate of coverage, we strongly encourage our providers to file claims for these services with us. If the service is determined not to be covered by workers’ compensation or the particular contract does not exclude these types of services, you risk any future consideration by failing to meet administrative filing requirements. The current administrative claims process may deny an initial claim for employment related injuries however, please contact Customer Service so that we can work with your office to apply the appropriate member benefits.

Coordination of benefits does not apply in any of these scenarios.

Insurance CO-ordination benefits

Coordination of Benefits

Other health insurance coverage information is important in the coordination of benefits (COB) process.

COB occurs when a member is covered by two or more insurance plans.

You can assist in the COB process by asking your Blue Cross patients if they have other coverage and indicating this information in Block 9 on the CMS-1500 claim form.

When COB is involved, claims should be filed with the primary insurance carrier first. When an Explanation of Benefits (EOB) is received from the primary carrier, the claim then should be filed with the secondary carrier, attaching the primary carrier EOB.

If claims are filed with the primary and secondary insurance carrier at the same time and Blue Cross is the secondary carrier, claims will be pending for applicable other coverage information from the member. If the requested information cannot be obtained from the primary carrier’s explanation of benefits or the member has not provided a response to our other coverage questionnaire, the claim will be rejected within 21 days. Once a rejection appears on the Payment Register/Remittance Advice, the patient may be billed for the total charge.

Medicare Primary Coordination of Benefits

Blue Cross coordinates with Medicare like we do with any other carrier that is the primary carrier for OGB members.

Coordination of Benefits Questionnaire

To streamline claims processing and reduce the number of denials, a COB questionnaire is available to you online at www.bcbsla.com/providers >Forms for Providers. When treating Blue Cross members and you are aware that they might have other health insurance coverage such as Medicare, give them a copy of the questionnaire during their visit. Ask them to complete the form as soon as possible and send it to the Blue Plan through which they are covered. Members will find the appropriate contact information on their ID card.

Subrogation

Subrogation is a contract provision that allows healthcare insurers to recover all or a portion of claims payments if the member is entitled to recover such amounts from a third party. The third party’s liability insurance carrier normally makes these payments. A third party is another carrier, person or company that is legally liable for payment from the treatment of the claimant’s illness or injury. All claims you submit to Blue Cross must indicate if work-related injuries or illnesses are involved and if the services are related to an accident.

Providers should:

• Not require the Blue Cross member or the member’s attorney to guarantee payment of the entire billed charge.
• Not require the Blue Cross member to pay the entire billed charge up front.
• Not bill the Blue Cross member for amounts above the reimbursement amount/allowable charge.
• Charge the member no more than is ordinarily charged other patients for the same or similar service.
• Bill the member only for any applicable deductible, coinsurance, co-pay and/or noncovered service.
If amounts in excess of the reimbursement amount/allowable charge were collected, you should refund that amount to the member.

In the case of OGB claims, Blue Cross pursues recovery of claims payments and Blue Cross makes payments as applicable.

Filing Claims with NPIs

Your NPI is used for claims processing and internal reporting. Claim payments are reported to the Internal Revenue Service (IRS) using your tax identification number (TIN). To appropriately indicate your NPI and TIN on UB-04 and CMS 1500 claim forms, follow the corresponding instructions for each form included in this manual. Remember, claims processing cannot be guaranteed if you have not notified Blue Cross of your NPI, by using one of the methods above, prior to filing claims. See the first part of this section for more details on how to submit claims to Blue Cross.

For more information, including whom should apply for an NPI and how to obtain your NPI, visit our website or CMS’ site at  www.cms.hhs.gov/NationalProvIdentStand. If you have any questions about the NPI relating to your Blue Cross participation, please contact us at 1-800-716-2299, option 3.




National Provider Identifier (NPI)

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires the adoption of a standard unique identifier for healthcare providers. The Centers for Medicare and Medicaid Services (CMS) has assigned national provider identifiers (NPIs) to comply with this requirement. NPIs are issued by the National Plan and Provider Enumeration System (NPPES). This one unique number is to be used when filing claims with Blue Cross as well as with federal and state agencies, thus eliminating the need for you to use different identification numbers for each agency or health plan.
To comply with the legislation mentioned above, all covered entities must use their NPI and corresponding taxonomy code, where applicable, when filing claims. All providers who are being credentialed or who are undergoing recredentialing, regardless of network participation, must include their NPI(s) on their application. Claims processing cannot be guaranteed unless you notify Blue Cross of your NPI(s) prior to filing claims using your NPI(s).

Notifying Blue Cross of your NPI

Once you have been assigned an NPI, please notify us as soon as possible. To do so, you may use one of the following ways:

1. Include it on your Louisiana Standardized Credentialing Application (LSCA), Health Delivery Organization (HDO) Application or Blue Cross recredentialing application.

2. Include it on the online Provider Update Form at www.bcbsla.com/providers >Forms for Providers.

3. Submit it along with your name and tax-ID or social security number printed on your office letterhead by fax to 225-297-2750 or by mail to Blue Cross and Blue Shield of Louisiana; Attn.
Network Administration; P.O. Box 98029; Baton Rouge, LA 70898-9029.


Referring Physician NPIs

Referring physician NPIs are required on all applicable claims filed with Blue Cross and HMO Louisiana. Place the NPI in the indicated blocks of the referenced claim forms:

• CMS -1500: Block 17a
• UB-04: Block 78
• 837P: 2310A loop, using the NM1 segment ad the qualifier of DN in the NM101 element
• 837I: 2310D loop, segment NM1 with the qualifier of DN in the NM101 element
For more information on NPIs, visit www.bcbsla.com/providers >NPI.

CMS-1500 Claims Filing Guidelines

Blue Cross scans all paper claims to eliminate the need to manually enter the claims data into our system. Please follow the guidelines below to ensure that your claims are scanned properly, which will allow you to benefit from faster, more accurate claims processing:

• Blue Cross does not accept black and white hardcopy claim forms. Do not submit black and white copies, as data recoginition can be affected and may delay the processing of claim payments. Black and white claims are less legible after they are scanned.

• Laser printed claims produce the best scanning results. If you use a dot-matrix printer, please use a standard 10 or 12 font ribbon when the type begins to fade.

• Use CMS-1500 forms that are printed on good quality paper. When the paper is too thin, the claim cannot be scanned properly.

• Type or computer print all information within the appropriate blocks on the CMS-1500 claim form. Information should not overlap from one block into another.

• Type or computer print Block 14. This information cannot be handwritten because only typed information can be scanned and converted to text file for our system to process.

• If there is a signature in Block 31, it should not overlap into Block 25 (Federal Tax ID number) because the Tax ID number cannot be read.

• Do not use any stamps or stickers on your claim forms. The scanning equipment has a lamp that distorts stamps with black ink and completely removes any information with red ink. Therefore, stamps with pertinent information in red ink, such as “Benefits Assigned” or “Corrected Copy,” will be lost if the claim is scanned.

Health Insurance Claim Form (CMS-1500 Version 02-12) Explanation

Block 1    Type(s) of Health Insurance - Indicate coverage applicable to this claim by checking the appropriate block(s).

Block 1A   Insured’s I.D. Number - Enter the member’s Blue Cross and Blue Shield identification number, including their three-character alpha prefix, exactly as it appears on the identification card.

Block 2 Patient’s Name - Enter the full name of the individual treated.

Block 3 Patient’s Birth Date - Indicate the month, day and year. Sex - Place an X in the appropriate block.

Block 4 Insured’s Name - Enter the name from the identification card except when the insured and the patient are the same; then the word “same” may be entered.

Block 5 Patient’s Address - Enter the patient’s complete, current mailing address and phone number.

Block 6 Patient’s Relationship to Insured - Place an X in the appropriate block. Self - Patient is the member. Spouse - Patient is the member’s spouse. Child - Patient is either a child under age 19 or a full-time student who is unmarried and under age 25 (includes stepchildren).

Other - Patient is the member’s grandchild, adult-sponsored dependent or of a relationship not covered previously.

Block 7 Insured’s Address - Enter the complete address; street, city, state and zip code of the policyholder. If the patient’s address and the insured’s address are the same, enter “same” in this field.

Block 8 Reserved for NUCC USE - This section is reserved for NUCC use. Deleted “Patient Status” and content of field.

Block 9 Other Insured’s Name - If the patient has other health insurance, enter the name of the policyholder, name and address of the insurance company and policy number (if known).

Block 10 Is patient’s condition related to: a. Employment (current or previous)?; b. Auto Accident?;

c. Other Accident?. Check appropriate block if applicable.

Block 10D When applicable, use to report appropriate claim codes. Applicable claim codes are designated by the NUCC. Please refer to the most current instructions from the public or private payer regarding the need to report claim codes. When required by payers to provide the sub-set of Condition Codes approved by the NUCC, enter the Condition Code in this field. The Condition Codes approved for use on the CMS-1500 Claim Form are available at www.nucc.org under Code Sets. When reporting more than one code, enter three blank spaces and then the next code.

Block 11 Not required.

Block 11D When appropriate, enter an X in the correct box. If marked “YES,” complete 9, 9A, and 9D.
Only mark one box.

Block 12 Patient’s or Authorized Person’s Signature - Appropriate signature in this section authorizes the release of any medical or other information necessary to process the claim. Signature or “Signature on File” and date required. “Signature on File” indicates that the
signature of the patient is contained in the provider’s records.


Block 13 Insured’s or Authorized Person’s Signature - Payment for covered services is made directly to participating providers. However, you have the option of collecting for office services from members who do not have a copayment benefit and having the payments sent to
the patients. To receive payment for office services when the copayment benefit is not applicable,
Block 13 must be completed. Acceptable language is:
a. Signature in block d. Benefits assigned
b. Signature on file e. Assigned
c. On file f. Pay provider
Please Note: Assignment language in other areas of the CMS-1500 claim form or on any attachment is not recognized. If this block is left blank, payment for office services will be sent to the patient. Completion of this block is not necessary for other places of treatment.


Block 14 Enter the 6-digit (MM/DD/YY) or 8-digit (MM/DD/YYYY) date of the present illness, injury or pregnancy. For pregnancy, use the date of the last menstrual period (LMP) as the first date. Enter the applicable qualifier to identify which date is being reported.


Block 15 Enter another date related to the patient’s condition or treatment. Enter the date in the date in the 6-digit (MM/DD/YY) or 8-digit (MM/DD/YYYY) format. Enter the applicable qualifier to identify which date is being reported.

Block 16 Dates Patient Unable to Work in Current Occupation - Enter dates, if applicable.


Block 17 Enter the name (First Name, Middle Initial, Last Name) followed by the credentials of the professional who referred or ordered the service(s) or supply(ies) on the claim. If multiple providers are involved, enter one provider using the following priority order:
1. Referring Provider
2. Ordering Provider
3. Supervising Provider
Do not use periods or commas. A hyphen can be used for hyphenated names. Enter the applicable qualifier to identify which provider is being reported to the left of the vertical, dotted line.

Block 17A Other ID#. The non-NPI ID number of the referring physician, when listed in Block 17.

Block 17B NPI – Required. Enter the national provider identifier (NPI) for the referring physician, when listed in Block 17.


Block 18 For Services Related to Hospitalization - Enter dates of admission to and discharge from hospital.

Block 19 Additional Claim information to be completed by NUCC.

Block 20 Laboratory Work Performed Outside Your Office - Enter, if applicable.

Block 21 Diagnosis or Nature of Illness or Injury - Enter the applicable ICD indicator to identify which version of ICD codes is being reported: “0” for ICD-10-CM codes- Note:
All transactions, electronic or paper-based, for services on and after October, 1, 2015, must contain ICD-10 codes or they will be rejected. Blue Cross will not accept ICD-9 codes with dates of services on or after October 1, 2015. Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. Enter the codes to identify the patient’s diagnosis and/or condition. Use the most specific diagnosis codes when reporting codes. List no more than 12 ICD-10-CM diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. Do not provide narrative description in this field.

Block 23 Prior Authorization Number - Enter the authorization number obtained from Blue Cross HMO Louisiana, if applicable.

Block 24A Date(s) of Service - Enter the “from” and “to” date(s) for service(s) rendered. Report the NDC in the shaded area.

We follow CMS billing requirements for CMS1500 claims when billing the NDC codes: (CMS Claims Processing Manual, chapter 26, section 10.4) states the following:

Item 24 - The six service lines in section 24 have been divided horizontally to accommodate submission of supplemental information to support the billed service. The top portion in each of the six service lines is shaded and is the location for reporting supplemental information. It is not intended to allow the billing of 12 service lines.

When required to submit NDC drug and quantity information submit the NDC code in the red shaded portion of the detail line item in positions 01 through position 13. The NDC is to be preceded with the qualifier N4 and followed immediately by the 11 digit NDC code (e.g. N499999999999). Report the NDC quantity in positions 17 through 24 of the same red shaded portion. The quantity is to be preceded by the appropriate qualifier: UN (units), F2 (international units), GR (gram) or ML (milliliter). There are six bytes available for quantity. If the quantity is less than six bytes, left justify and space-fill the remaining positions (e.g., UN2 or F2999999).

Block 24B Place of Service - Enter the appropriate place of service code. Common place of service codes are: Inpatient - 21 Outpatient - 22 Office - 11

Block 24C EMG - Enter the Type of Service code that represents the services rendered.

Block 24D Procedures, Services, or Supplies - Enter the appropriate CPT or HCPCS code. Please ensure your office is using the most current CPT and HCPCS codes and that you update your codes annually. Append modifiers to the CPT and HCPCS codes, when appropriate.

Block 24E Diagnosis Pointer - Enter the diagnosis code reference letter (pointer) as shown in Block 21 to relate the date of service and procedures performed to the primary diagnosis. When multiple services are performed, the primary reference letter for each service should be listed first, other applicable services should follow. The reference letter(s) should be A-L or multiple letters as applicable. ICD-10-CM diagnosis codes must be entered in Block 21 only.

Do not enter them in 24E.
Block 24F Charges - Enter the total charge for each service rendered. You should bill your usual charge to Blue Cross regardless of our allowable charges.

Block 24G Days or Units - Indicate the number of times the procedure was performed, unless the code description accounts for multiple units, or the number of visits the line item charge represents. Base units value should never be entered in the “units” field of the claim form.

Block 24J Rendering Provider ID# - Enter the national provider identifier (NPI) for the rendering physician for each procedure code listed when billing for multiple physicians’ services on the same claim. Laboratory, Durable Medical Equipment, Emergency Room Physicians,

Diagnostic Radiology Center, Laboratory and Diagnostic Services and Urgent Care Center providers do not have to enter a physician NPI in this block. Please enter the facility NPI in blocks 32A and 33A as instructed.

*Rural health clinics and Federally Qualified Health Centers are required to enter the rendering provider NPI.

Block 25 Federal Tax I.D. Number - Enter the provider’s/clinic’s federal tax identification number to which payment should be reported to the Internal Revenue Service.

Block 26 Patient’s Account Number - Enter the patient account number in this field. As many as nine characters may be entered to identify records used by the provider. The patient account number will appear on the Provider Payment Register/Remittance Advice only if it
is indicated on the claim form.

Block 27 Accept Assignment - Not applicable - Used for government claims only.

Block 28 Total Charge - Total of all charges in Item F.

Block 29 Amount Paid - Not required.

Block 30 Not required.

Block 31 Signature of Provider - Provider’s signature required, including degrees and credentials.

Rubber stamp is acceptable.

Block 32 Name and Address of Facility - Required, if services were provided at a facility other than the physician’s office.

Block 32A NPI - Enter the NPI for the facility listed in Block 32.

Block 32B Other ID. The non-NPI number of the facility refers to the payer-assigned unique identifier of the facility.

Block 33 Billing Provider Info & Ph# - Enter complete name, address, telephone number for the billing provider.

Block 33B Other ID#. The non-NPI number of the billing provider refers to the payer-assigned unique identifier of the professional.

Block 33A NPI - Enter the NPI for the billing provider listed in Block 33.

Complications of Upper Endoscopy

What are the Possible Complications of Upper Endoscopy?

Endoscopy is generally safe.  Complications can occur, but are rare when the test is performed by physicians with specialized training and experience in this procedure.  Bleeding may occur from a biopsy site or where a polyp was removed.  It is usually minimal and rarely requires blood transfusions or surgery.  Localized irritation of the vein where medication was injected may rarely cause a tender lump lasting for several weeks, but this will go away eventually.  Applying heat packs or hot moist towels may help relieve discomfort.  Major complications, e.g., perforation (a tear that might require surgery for repair) are very uncommon.

Upper GI (UGI) endoscopy is commonly performed and carries a low risk of adverse events. Large series report adverse event rates of 1 in 200 to 1 in 10,000 and mortality rates ranging from none to 1 in 2000.1-6 Data collected from the Clinical Outcomes Research Initiative database show a cardiopulmonary event rate of 1 in 170 and a mortality rate of 1 in 10,000 from among 140,000 UGI endoscopic procedures.7 The variability in rates of adverse events may be attributed to the method of data collection, patient populations, duration of follow-up, and definitions of adverse events. Some authors include minor incidents, such as transient hypoxemia or self-limited bleeding as adverse events, whereas others report only significant adverse events that prevent completion of the procedure or result in hospitalization.8 Additionally, the majority of publications rely on self-reporting, and most reported data collected only from the immediate periprocedure period, thus the rate of late adverse events and mortality may be underestimated.8,9 Major adverse events related to diagnostic UGI endoscopy are rare and include cardiopulmonary adverse events, infection, perforation, and bleeding


Cardiopulmonary adverse events

Most UGI procedures in the United States and Europe are performed with patients under sedation (moderate or deep).12 Cardiopulmonary adverse events related to sedation and analgesia account for as much as 60% of UGI endoscopy adverse events.1-4,7 The rate of cardiopulmonary adverse events in large, national studies is between 1 in 170 and 1 in 10,000.1-4,6,7 Reported adverse events range from minor incidents, such as changes in oxygen saturation or heart rate, to significant adverse events such as aspiration pneumonia, respiratory arrest, myocardial infarction, stroke, and shock. Patient-related risk factors for cardiopulmonary adverse events include preexisting cardiopulmonary disease, advanced age, American Society of Anesthesiologists class III or higher, and an increased modified Goldman score.13,14 Procedurerelated risk factors for hypoxemia include difficulty with intubating the esophagus, a prolonged procedure, and a patient in the prone position.7,8,15,16 For a detailed discussion and specific recommendations, the reader is referred to the ASGE document “Sedation and Anesthesia in GI Endoscopy”17 and the “American Society of Anesthesiology Practice Guidelines for Sedation and Analgesia by Nonanesthesiologists

Bleeding

Clinically significant bleeding is a rare adverse event of diagnostic UGI endoscopy.31 Mallory-Weiss tears occur in less than 0.5% of diagnostic UGI endoscopic procedures and usually are not associated with significant bleeding.32 Bleeding may be more likely in individuals with thrombocytopenia and/or coagulopathy.1 The minimum threshold platelet count for the performance of diagnostic UGI endoscopy has not been established. UGI endoscopy with biopsy was shown to be safe in 1 study of adults with solid malignancies and platelet counts greater than 20,000/mL.33 Two case series of UGI endoscopy with or without biopsies in children with platelet counts greater than 50,000/mL reported no bleeding adverse events.34,35 However, a larger study of 198 UGI endoscopies in children after stem cell transplantation demonstrated that the risk of bleeding requiring red blood cell transfusions after UGI endoscopic biopsies was 4% despite a minimum platelet count of 50,000/mL.36 Four of these 8 patients were found to have duodenal hematomas. Thus, some authors have concluded that diagnostic UGI endoscopy can be performed when the platelet level is 20,000/mL or greater and that a threshold of 50,000/mL should be considered before performing biopsies.3

More Effective GI Billing With Modifier -22

Five Pointers for More Effective GI Billing With Modifier -22

A colonoscopy is performed on a patient with a tortuous colon. Instead of taking the usual 20 minutes to complete, the gastroenterologist spends 90 minutes navigating the scope through the twists and turns of the patients lower intestine. Modifier -22 (unusual procedural services) is attached to the colonoscopy procedure code when the claim is filed, but the gastroenterologist feels a sense of frustration because he knows from experience that it is unlikely he will receive extra reimbursement despite his extra service. There is a way to ensure better pay up for these prolonged or unusual procedures.

Modifier -22 should be used when the service provided is above and beyond the scope of a normal procedure, says Pat Stout, CMC, CPC, an independent gastroenterology coding consultant and president of OneSource, a medical billing company in Knoxville, Tenn.

One reason for the lack of additional payment is that modifier -22 has been used inappropriately in the past. Modifier -22 has been so overutilized that many payers have quit acknowledging it, Stout says.

In recent years, Medicare has tried to crack down on what it believes is the inappropriate use of the modifier. In its January 1998 Medicare bulletin, Cigna Medicare, the Part B administrator for Tennessee, North Carolina and Idaho, complained that it sees much inappropriate use of modifier -22. Some physicians use it on almost all of their surgical procedures.


Extra Documentation Required

Changes to consultation codes

For several years, CMS has argued that physicians were not using consultation codes properly. They were using such codes in situations where patients were self-referred, where no documentation of consultation was evident from the referring source’s chart or where the physician was expected to assume care of part or all of the patient’s problems at the first encounter (the so-called transfer of care). Despite opposition from the specialty societies, in the final rule, CMS has decided to stop making payments for consultation services starting January 1, 2010, stating that in most cases, there is no substantial difference in work between consultations and visits. CMS directs that the inpatient consultation codes (99251-99255) will now be reported with the 99221-99233 inpatient initial admission service codes. In the office setting, the consultation codes (99241-99245) should be reported with codes from the 99201-99205 series if the patient is new or has not been seen within three years for a face-to-face Evaluation and Management (E/M) encounter, and with codes 99212-99215 if the patient has been seen within three years.