Electronic Claim Submission

Question
What are the benefits of filing electronically?

Answer
Filing claims electronically is the first step towards a fully electronic office. Your payments are processed at a faster rate, typically two to four days versus a paper claim that could take up to nineteen days.

Receiving audit trails electronically can save you time and money. Electronic audit trails optimize the benefits of electronic claims by providing you with documentation regarding the status of your claims transmission without the delay of mail. Claims transmitted before 3:30 p.m. produce audit trails available the following business day allowing you to correct and resubmit claims that have errors. The ability to retrieve an electronic remittance is also available.

If you submit your claims electronically, you are qualified to receive electronic access to patient account information including benefits and eligibility, claims status, fee schedule and payment history information. Additionally, if you choose to participate in all of the Blue Cross electronic options and would like to receive electronic funds transfer, you are eligible for direct deposit of your
Blue Cross check.

Question
How much does it cost to establish an electronic connection with Blue Cross?

Answer
The amount of money spent can vary greatly depending on the features and functionality that you desire. Below are the approximate costs of each method:

• Validated vendor – The charge for an electronic connection through a validated vendor is usually included in the practice management software package. A communication service charge may apply. Contact the vendor of your choice for pricing details. Connectivity is available through direct dial-up or frame relay in most cases.
• Clearinghouse – A clearinghouse can either be its own validated vendor that only handles claim submission, audit trail and remittance retrieval or it can be incorporated as part of another validated vendor practice management software system that handles the claims system within that product. Connectivity is available through direct dial-up or frame relay in most cases.
• PCEMC+ – Blue Cross and Blue Shield of Alabama provides the PCEMC+ software at no charge. Distribution of the software is handled by select PCEMC+ Vendors who may charge for installation, training and support of the free software. In order to communicate with Blue Cross, users must establish a connection directly to Blue Cross. There is no charge for dialing locally to the Birmingham telephone number. Providers that cannot dial local to the Birmingham area can choose to use regular long distance services or a BellSouth Ring-To communication service. Connectivity is also available through frame relay.

Note: A modem is not required for frame relay connection.

• File Transfer Protocol (FTP) – Some validated vendors offer FTP as a connection option. The use of a vendor product or “script” would bear a higher cost than programming directly from your office; however, it would most likely offer user-friendly functionality and support. Although FTP is one of the options some of our validated vendors have programmed, it can be used without a vendor product to connect directly to Blue Cross. We recommend at least one of your staff members have a technical ability if you intend to have your office staff perform the initial setup for this option. The cost would be the acquirement of a PC with dial-up capabilities, a modem and the telephone charges for connection to a Birmingham area call. Connectivity is available through direct dial-up or frame relay.
• Internet – There is no charge to access the features of the Blue Cross and Blue Shield of Alabama web site. The only cost will be that of a PC with a browser and an Internet Service Provider. This option is not available for Medicare information. Connectivity is also available through direct dial-up or frame relay.

Question
How long does it take to get set up for electronic filing?

Answer
The amount of time varies depending on which method of electronic communication you choose. Internet set-up typically takes 7 to 10 days. All other methods depend on the vendor involved. However, the policy of EDI Services is to complete processing of paperwork within 48 hours of receipt.

Question
What are the pros and cons of the different claim filing methods?

Answer
There are a number of different methods available for submitting your claims electronically. Below are your options:

Validated InfoSolutions/Electronic Practice Management (e-PM) Software – A provider may access various subsystems provided by Blue Cross and Blue Shield of Alabama through InfoSolutions®. The InfoSolutions/e-PM system refers to all of the business transactions where InfoSolutions/Patient Health Information refers to clinical transactions. E-PM transactions include three main systems: the claims system which allows a provider to send his claims electronically as well as retrieve remittances and audit trails; the patient accounts system which allows a provider to check claims status, eligibility and benefits, fee schedule information and payment history electronically; and the referral system which allows a provider to review and submit referrals.

Pros: Provides access to all Blue Cross Professional, Dental and Medicare Part B electronic options.
Cons: Typically the most expensive option.

• Filing through a claims clearinghouse
  Pros: Clearinghouses offer the ability to file claims to multiple carriers with one submission.
  Cons: Often charge on a per claim basis. May not forward all claims electronically.
• PCEMC+ software – You may submit via PCEMC+ by directly keying your claims or by interfacing PCEMC+ with your current practice management system. The PCEMC+ software will also provide you with the ability to check a patient's eligibility and benefits, retrieve audit
  trails, check claim status, review provider payment history and retrieve electronic remittances for Blue Cross and Blue Shield of Alabama subscribers (professional and dental benefits) and Alabama Medicare Part B beneficiaries.

Pros: Least expensive InfoSolutions interface for both Medicare and Blue Shield lines of business.
Cons: Does not offer practice management options (i.e., appointment scheduling and
remittance posting).

• File Transfer Protocol (FTP) – FTP is a method of claims transmission allowing the provider to dial in and transmit a compressed claims file to Blue Cross and Blue Shield of Alabama. You may also retrieve audit trails and remittances via FTP. Many validated InfoSolutions/e-Practice Management (e-PM) vendors offer an FTP option, however, you may also choose to connect directly to Blue Cross without a vendor written script as long as your software can create a correctly formatted claim file.

Pros: FTP is the most widely accepted method of file transfer.
Cons: FTP only offers claims transmission, audit trail, and remittance transfer.

• Blue Cross and Blue Shield of Alabama's web site (www.bcbsal.com) - The web site offers users the ability to file non-Medicare claims directly to Blue Cross. Other options available include retrieving audit trails and remittances electronically, fee schedule information, referrals, and patient account information.

Pros: Least expensive alternative. Accessible from any Internet capable personal computer.
Cons: Cannot file or retrieve Medicare information. Cannot interface directly with a practice management software system.

Question
What is InfoSolutions®?

Answer
InfoSolutions® is a Medical Information Network developed to provide more complete patient health information to healthcare providers and to provide a more stable environment for electronic information exchange. By providing a more complete medical history, medical professionals can make a more informed decision regarding the health of their patients. Blue Cross and Blue Shield of Alabama has extensive electronic data interchange services available for use by practice management vendors. Both business and clinical information is available if access to those subsystems is available through your practice management software and the appropriate authorization has been granted. Although it is the name of all the information we house on our patients, the word InfoSolutions is commonly used to refer to the clinical messages whereas Electronic Practice Management (e-PM) is the name we use to refer to the business messages.

Question
What are the system requirements for each method?

Answer
Validated vendor – The hardware requirements vary by vendor. A Network Unique Identifier (NUI) provided by BellSouth may also be required.

Clearinghouse – The hardware and connectivity requirements vary by clearinghouse.

PCEMC+ – A personal computer with a modem and the PCEMC+ software. The minimum hardware requirements are 64 MB of system memory, Pentium 133 MHz processor (Pentium II-350 for larger claims volume), CD-ROM Drive, SVGA monitor with 800 x 600 minimum resolution. Software requirements are Windows 98 Second Edition operating system or higher, and a 56K baud rate modem.

File Transfer Protocol (FTP) – FTP requires a personal computer with a TCP/IP stack (typically part of the operating system from Windows 95 and up), an FTP executable, and compression software such as PKZIP or WinZip.

Internet applications – Requires a personal computer with browser software and Internet Service Provider (ISP) access.

Question
Do I need to go through a vendor or can I use the web applications?

Answer
Due to Federal regulation, only non-Medicare information may be transmitted through the Internet. The volume of claims that your office files can determine whether or not the web applications are practical and cost effective for you. The web applications do not offer the extensive functionality of some practice management systems (i.e., interface with your schedule or patient software).

Question
How do I get a list of validated vendors?

Answer
You may download the most recent Vendor Functionality Matrix (VFM) and PCEMC+ Distributor List from the Blue Cross and Blue Shield of Alabama web site at the following link:

http://www.bcbsal.com/providers/pdfs/VFM Matrix Physician.pdf

Otherwise, you may submit an e-mail request to EMC@bcbsal.org for an electronic copy or contact your EDI Services Representative at 205 220-6899.

Question
Who is the best vendor or who do we recommend?

Answer
Blue Cross and Blue Shield of Alabama does not make specific recommendations. Each vendor listed in the Vendor Functionality Matrix (VFM) must meet the same set of criteria to be validated for each system.

Question
What is the difference between a validated vendor and a PCEMC+ vendor/distributor?

Answer
A validated vendor is one that has developed a software product designed to interface with the information within the InfoSolutions/e-PM systems.

A PCEMC+ vendor/distributor is one that has been approved to install and support the Blue Cross and Blue Shield of Alabama PCEMC+ software.

Question
What features should I look for in a practice management system?

Answer
The Vendor Functionality Matrix only lists the functions that are validated by Blue Cross and Blue Shield of Alabama. Many vendor practice management systems have additional features not listed in the matrix; therefore, we have included some suggested questions you may want to ask a vendor when "shopping around" for a computer system. The suggested questions are attached to the back of the packet titled “If you choose a Validated Vendor System.”

Question
What types of claims can be sent electronically?

Answer
All methods (except Internet) – Institutional (Facility) or Professional (Medical and Dental) including Anesthesia, Durable Medical Equipment (DME), Ambulance, Chiropractic and most other claim types may be filed electronically.

Internet – Only non-Medicare claims may be transmitted through the Internet. Blue Cross currently accepts Professional (Medical and Dental) including Anesthesia, DME, Home Health claims, and most other Professional claim types.

Question
Do I have to participate in submitting electronic Patient Medical Information to file my claims electronically?

Answer
No. You may participate in all of the e-PM electronic options offered by Blue Cross and Blue Shield
of Alabama without participating in electronic Patient Medical Information submission.

Question
Do I have to go through a clearinghouse or can I send directly to Blue Cross?

Answer
Both direct connections to Blue Cross or the use of a clearinghouse are options available for electronic claims submission. The choice is up to you.

Question
What is the benefit of a clearinghouse?

Answer
The benefit of a clearinghouse is that you may send all of your claims electronically in one transmission. The clearinghouse will then route all of your claims to the appropriate carrier. Not all clearinghouses provide an electronic connection with Blue Cross and Blue Shield of Alabama. Those that do not connect electronically to Blue Cross submit your claims on paper. If you choose to send your claims through a clearinghouse, verify that they have an electronic connection with Blue Cross. We cannot consider you an electronic submitter if we receive your claims on paper even if you submit them electronically to your clearinghouse. We must receive them electronically as well.

Question
Can I send attachments electronically?

Answer
Currently, there are no claim attachments that are required to be submitted electronically.

Last Updated November 2007