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Proper payment of Medicare Advantage claims is a result of the joint efforts of providers, employee clinicians and billing personnel. This goal requires meeting payment policy requirements that combine national and local policy. This section introduces common claim errors that result in claim rejections or claim denials, and describes the general requirements for properly resubmitting or appealing denied claims. If Blue Cross and Blue Shield of Alabama does not pay a claim as submitted, there are three general reasons described below:
• Billing/data entry errors
• Non-compliance with coverage policy
• Billing for services that are not medically necessary
What Constitutes a Billing/Claim Filing Error
In many cases, Blue Cross cannot pay a claim as the provider initially submitted it because the claim needs additional documentation or a correction to the claim data. Billing or data entry errors/omissions generally indicate that required fields were left blank [e.g., no International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) admitting diagnosis code entered in Field Locator (FL)/Block 76 of the CMS-1500 claim form]. Errors could occur in situations when providers enter improper bill types, also.
One such example is a claim a provider submitted with a discharge bill type (FL/Block 4) but the status code (FL/Block 22) indicates that the patient was still in the facility.
Following are common claim errors that result in claim denials:
• Incorrect member alpha-prefix and ID number
• Invalid/missing diagnosis code or procedure code
• Claim filed after the timely filing limit
• Incorrect provider number
• Missing, incorrect or invalid modifier
• Missing or incorrect quantity billed
Blue Advantage is a Medicare-approved PPO Plan.
Last Updated December 2013