\ Preferred Physical Therapist Manual

Preferred Physical Therapist Manual

Revised November 2000

CPT five-digit codes, nomenclature and other data are copyright 1999 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or listings are included in CPT. The AMA assumes no liability for the data contained herein.

PREFACE

We welcome you to Blue Cross and Blue Shield of Alabama’s Preferred Physical Therapy (PPT) Network.

A provider number has been assigned to you which also includes Provisional status for a two-year period. Your performance and compliance will be evaluated throughout the two-year provisional period in order to determine continued PPT participation. The provider number should be used when filing Blue Cross and Blue Shield of Alabama claims. The issuance of this number is not a guarantee of payment. Benefits for your services will be determined based on contract coverage for the member.

Becoming, and remaining, the number one Preferred Provider Organization in the country is the result of the successful partnership Blue Cross has formed with participating providers. We look forward to partnering with you in order to ensure the high level of care our members have come to expect.

This manual has been compiled for the Preferred Physical Therapist Program implemented by Blue Cross and Blue Shield of Alabama. It will assist in the completion of claim and precertification forms as well as assist with other administrative matters.

General Program Guidelines

The guidelines contained within this manual are not intended in any way to imply that treatment rendered over and above these limits constitutes over utilization or that if treatment is provided within these guidelines payment will be made. All claims for treatments are subject to review for appropriateness of treatment, medical necessity, and contract limitations by a qualified reviewer. All treatment must include proper documentation for services rendered.

Medical necessity must be documented for all services rendered. All charts will be reviewed for inclusion of an evaluation, plan of care, physical exam findings, and progress or treatment notes. Payment is made in accordance with the Benefit Agreement applicable to the patient. The patient must be covered by a Benefit Agreement providing physical therapy benefits at the time services are rendered.

Covered Services

For physical therapy to be medically necessary, it must be reasonable and necessary for
the patient’s diagnosis or the treatment of the patient’s condition. Medical Necessity is
indicated when:

1.

The diagnosis established by the physician supports utilization of the therapy.

2.

There is documentation of objective physical and functional limitations. (strength/ROM/mobility/ADL levels).

3.

There is a plan of care that includes treatment services that are expected to result in improvement of these limitations in a reasonable and generally predictable period of time. The amount, frequency, and duration of services must be reasonable.

4.

The services are one-to-one.

5.

The services are skilled. The services must be of a level of complexity and sophistication, or the condition of the patient must be such that the services required can be safely and effectively performed only by a qualified physical therapist or under his/her supervision when allowed by contract.

Services such as the application of hot and cold packs, use of exercise equipment, and repetitive exercises do not ordinarily require the skills and full attention of a qualified physical therapist, and therefore are not separately billable. If such treatments are given as a prerequisite to a skilled physical therapy procedure, they are considered part of that modality and are not separately billable.

Non-Covered Services

Preferred Physical Therapists are responsible for notifying the patient of services that are not medically necessary for the treatment of his/her condition. Click here to view a sample Non-Covered Services Statement that can be used to explain to the patient that he/she is responsible for those charges. The patient should sign the statement before the services are rendered. Be sure to keep the signed copy in the patient's medical record.

Examples of Non-Covered Services:

1.

No physician referral for treatment.

2.

When services are considered a routine part of nursing care (turning patients to prevent pressure areas, walking patients to maintain mobility, routine dressing changes).

3.

Services which do not require the professional skills of a qualified physical therapist to perform (hot packs/cold packs, except for instances of documented paresthesias, wounds).

4.

Repetitive services/treatments not requiring the skills of a physical therapist–general supervision of exercises previously taught to patient or caregiver, exercise equipment, stairmaster, treadmill, bicycle.

5.

Group therapy.

6.

Services related to activities for the general good and wellbeing of patients such as general exercise to promote overall fitness and flexibility, and activities to provide diversion or general motivation.

7.

Endurance enhancing activities/aerobic conditioning, weight reduction.

8.

If patient’s expected restoration potential is insignificant in relation to the extent and duration to the physical therapy services required to achieve such potential.

9.

Passive exercises not related to restoring specific loss of function.

10.

Maintenance care–lack of progress in restoring function/plateau.

When Patients Should Be Discharged

1.

Goals have been achieved.

2.

There is no expectation of significant progress.

3.

The patient is unable to participate in treatment program for medical, psychological, or social reasons.

4.

Non-compliance to treatment plan.

5.

The patient is restored to normal ADL functioning level.

Covered Providers

·

Licensed Physical Therapists

·

Physical therapy (PT) students are covered providers when working under the direct on-site supervision of a Preferred Physical Therapist. All treatment notes must be co-signed by the supervising/PPT. Services should be billed using the supervising physical therapist’s provider number.

·

Physical therapists with temporary licenses are covered providers when working under the direct on-site supervision of a Preferred Physical Therapist. All treatment notes must be co-signed by the supervising/PPT. Services should be billed using the supervising physical therapist’s provider number.

·

Licensed physical therapist assistants (PTA) are covered providers when working under the direction of a Preferred Physical Therapist with the following provisions:

 

1.

The physical therapist must interpret the practitioner’s referrals.

 

2.

The physical therapist must perform the initial evaluation.

 

3.

The physical therapist must develop the treatment plan and program, including long and short-term goals.

 

4.

The physical therapist must identify and document precautions, special problems, contraindications, goals, anticipated progress and plans for reevaluation.

 

5.

The physical therapist must reevaluate the patient and adjust the treatment plan, perform the final evaluation and discharge planning.

 

6.

The physical therapist must implement (perform the first treatment) and supervise the treatment program.

   

a)

The physical therapist must co-sign each treatment note written by the PTA.

   

b)

The physical therapist must indicate he/she has directed the care of the patient and agrees with the documentation as written by the PTA for each treatment note.

   

c)

The physical therapist must render the hands-on treatment, and write and sign the treatment note every 6th visit.

Services should be billed using the supervising/Preferred Physical Therapist’s provider number.

·

Physical therapist assistant (PTA) students are covered providers when working under the direct on-site supervision of a Preferred Physical Therapist or under the direct on-site supervision of a licensed physical therapist assistant working under a PPT. All treatment notes must be co-signed by the supervising/PPT. Services should be billed using the supervising physical therapist’s provider number.

·

PTAs with temporary licenses are covered providers when working under the direct on-site supervision of a Preferred Physical Therapist or under the direct on-site supervision of a licensed physical therapist assistant with the approval of the supervising physical therapist. All treatment notes must be co-signed by the supervising/PPT. Services should be billed using the supervising physical therapist’s provider number.

Non-Covered Providers of Physical Therapy Services

Athletic trainers, exercise physiologists, massage therapists, RNs, LPNs, certified strength trainers, secretaries, office personnel.

Filing for occupational therapy and speech therapy services under a physical therapy provider number is not acceptable and is not reimbursable.

Documentation

The medical record should include:

1.

Completed precertification form.

2.

Signed physician referral – renewed every 30 days.

3.

Initial evaluation–signature and credentials of the person performing the evaluation

 

a)

History

 

b)

Diagnosis

 

c)

Prior level of functioning

 

d)

Objective documentation including strength, ROM, levels of functioning (bed mobility, transfers, ambulatory status, wheelchair mobility, activities of daily living)

 

e)

Problems

 

f)

Goals related to problems

 

g)

Treatment plan including frequency and time frame

4.

Reevaluations including objective/measurable data, recommended every four to six weeks.

5.

Progress notes referring back to goals and progress towards goals.

6.

Daily treatment notes documenting modalities and procedures – written and signed with credentials by the person performing the hands on treatment. Notes should describe treatment given and the response of the patient. A note must be written for each treatment and document each charge made.

7.

Discharge summary–including date of last visit, status, outcome of goals, and home programming.

All submitted documentation including initial evaluations, plans of care, treatment notes, progress notes, and discharge summaries must be written and signed by the person performing the hands on treatment of the patient. Therapist codes and stamps are not acceptable. Credentials such as P.T. or P.T.A. must accompany the signature. Unsigned notes and documentation will not be accepted.

When submitting documentation for review of isokinetic/computerized strength testing and ROM testing, the computerized printout must be included.

CPT Codes

Listed below are a few of the procedure codes covered under the PT Network. Special care should be given in reporting and documenting these services.

97140

Manual therapy techniques (mobilization, manipulation, manual lymphatic drainage, and manual traction), one or more regions, each 15 minutes.

 

Treatment must be diagnosis related and documentation must support proper billing of 97140 and contain the following:

 

a.

Description of specific area treated.

 

b.

Soft tissue technique utilized.

 

c.

Response of patient to treatment.

97010

Application of hot or cold packs does not ordinarily require the skills, expertise, and full attention of a qualified physical therapist and are not separately billable.

97750

Physical performance test or measurements (musculoskeletal, functional capacity), with written report. Blue Cross and Blue Shield of Alabama will allow the billing initially of two services of isokinetic testing for a comparison of the involved and uninvolved extremity. Follow-up testing may be billed monthly if medically necessary. Only one service may be billed at the follow-up testing. Billing a service for each motion of a joint is not reimbursable. Billing for this code should include torque curves and other graphic reports with interpretation.

97113, 97530, 97110

Documentation must justify the billing of multiple services.

97124

In order to be considered for coverage when billing therapeutic massage [Physicians’ Current Procedural Terminology (CPT) code 97124], the massage must be performed by a licensed physical therapist. Massage therapists, exercise physiologists, physician assistants, registered nurses, licensed practical nurses, athletic trainers, other assistants, and office personnel are not considered as providers eligible for coverage.

Therapeutic massage must be of a skilled nature, and must be part of a specific, diagnosis related goal. The services must be of a level of complexity and sophistication that they require the skills and expertise of a physician or physical therapist. Massage performed with hand-held devices such as vibrators is not considered skilled in nature and is not reimbursable.

(CPT only© 1999 American Medical Association. All Rights Reserved.)

Precertification

For patients initiating therapy on or after July 1, 2000, Preferred Physical Therapists must submit precertification for physical therapy services rendered to new patients beginning with the 16th visit. This process should not be initiated prior to the 14th visit. If precertification is not obtained, all services associated with the 16th and subsequent visits will be non-covered and the patient will be held harmless. Patients may be billed if they have signed a non-covered statement for each visit indicating that they have been properly informed that the services to be rendered are not covered by Blue Cross and Blue Shield of Alabama and that the patient will be responsible for paying for the services. There are no retroactive certifications for these contracts.

When filing a request for precertification, a completed precertification form should be submitted to:

Blue Cross and Blue Shield of Alabama

FAX 205 220-6631

ATTN: Physical Therapy Precertification

Click here to view a sample of the precertification form. If all requested information is not received, a determination will not be made. Determinations will be made within one business day of receipt of all information. Notification of the determination will be by letter or facsimile.

Precertification requests received after 2:00 p.m. will be considered as received the following business day.

Exceptions:

Precertification is not required for:

 

·

Contracts that are secondary to Medicare or any other insurance carrier.

 

·

ITS Host, NASCO, FEP, State of Alabama (group 13000) and Local/State Government (group 30000) contracts.

APPEALS OF DETERMINATION NOT TO PRECERTIFY

Expedited Appeal

When there is an imminent or ongoing service requiring review, the provider may request an Expedited Appeal by telephone, facsimile, or e-mail with additional information to be included in the review. Notification of the results of the appeal will be made by telephone to the provider within 24 hours of receipt of the request with written notification to follow.

Appeal requests should be mailed to:

Blue Cross and Blue Shield of Alabama

Post Office Box 362025

Birmingham, Alabama 35236

 

FAX 205 220-6631

Telephone for expedited appeals 205 220-6356 or 205 220-6051

When requesting an appeal, additional information to support the medical necessity of the requested visits should be included. Appeals should not be requested until covered visits are used. Appeals can only be requested when no additional treatments have been confirmed. There are no appeals of partial confirmation or approvals. For instance, if eight additional visits are requested by a Preferred Physical Therapist and four visits are approved by Blue Cross and Blue Shield of Alabama, the physical therapist may not request an appeal of this decision. The therapist must use the four visits and then request additional visits if he/she determines additional treatment is necessary.

Standard Appeal

Requests for a Standard Appeal of a decision not to certify additional visits must be made in writing by mail or facsimile by the provider and include the necessary medical records needed for the review if not submitted previously to Blue Cross and Blue Shield of Alabama.

Managed Care Decision Updates

Blue Cross and Blue Shield of Alabama updates the criteria by which our Managed Care medical decisions are made on an as-needed basis. The guidelines are reviewed frequently in relation to the following:

1.

Changes in current medical practice,

2.

Bulletins and recommendations from our Medical Review Committee,

3.

Input from our Quality Assurance Committee,

4.

Availability of new therapies and technologies,

5.

Review of utilization trends, and

6.

New surgical and treatment modalities.

When new guidelines or updates in the current guidelines are required, information is gathered from a review of the medical literature and expert clinical advisers. This information is given to our Medical Directors and the Medical Review Committee for review. Changes are made based on the Medical Directors and Committee's approval.

The medical review area works as a team consisting of many members throughout Blue Cross and Blue Shield of Alabama to evaluate and maintain the most cost-effective administration of health care without jeopardizing quality care.

Categories Evaluated

· Documentation

Complete, accurate, clear

· Coding

Must not be unbundled or upcoded

· Medical Necessity

Appropriate medical rationale must be present to support all services rendered.

· Billing

Precertification must be obtained prior to the ninth visit and balances written off when indicated.

Preferred Physical Therapist Audits

A major strength of Blue Cross and Blue Shield of Alabama in managing health care costs is our ability to audit Preferred Providers and effect changes in utilization practice habits. Our contractual arrangements give us the right to audit medical records of patients of Preferred Physical Therapists in order to objectively evaluate their coding, billing and practice patterns, as well as the completeness of their medical documentation.

An audit can be triggered by external referrals from members, group administrators, anonymous tips, and even other physical therapists who feel that a particular physical therapist, physical therapy group, or facility is not in compliance with the program requirements.

If an off-site audit reveals unusual practice patterns or billing procedures that result in overpayments, refunds are required from the physical therapist and the amount is returned to the groups whose subscribers were affected by the incorrect practices. Any physical therapist having an unsatisfactory audit must immediately correct any problems. A follow-up audit is performed to ensure that he/she is in compliance with the Preferred Physical Therapist guidelines. A second unsatisfactory audit can result in a physical therapist being removed from the Preferred Physical Therapy Program. These cases are referred to the Physical Therapist Advisory Committee for review. This committee is composed of five geographically distributed Preferred Physical Therapists.

GENERAL INFORMATION

Electronic Filing

As a Preferred Physical Therapist, you have agreed to file your claims electronically. Blue Cross and Blue Shield of Alabama publishes the Vendor Functionality Matrix (VFM) to keep the provider community informed about vendors who offer an electronic connection to us. The list includes vendors who are validated to access the InfoSolutions® Information Network as well as vendors who offer audit trail and remittance retrieval and electronic claim submission to their clients through File Transfer Protocol (FTP).

We hope the VFM will help keep the provider community informed about all validated vendors when considering the purchase or upgrade of a computer system.

Be sure to visit our Web page (http://www.bcbsal.org/) for the most current VFM. Click the following links to view the VFM:

Vendor Functionality Matrix

Vendor Functionality Matrix, page 1
Vendor Functionality Matrix, page 2

Vendor Grid Legend

The VFM legend explains what each component encompasses. We update the VFM monthly to include newly validated vendors as well as any additional validations for the vendors already listed. Included in the VFM are only the functions that Blue Cross and Blue Shield of Alabama validates. 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 for a computer system.

1.

Do you use a clearinghouse? If so, are the electronic claims I send to the clearinghouse forwarded to the appropriate insurer in an electronic format?

2.

Does your software offer electronic posting of remittances?

3.

What platform does your system use (Windows, UNIX, etc.)? (This may help you in determining how much, if any, additional hardware/software you may have to purchase.)

4.

Does your system offer an electronic transcription component?

5.

What type of database do you use? Does your software create a local database?

6.

Does your software offer the option of printing the data entered/retrieved?

Vendor Contact List

Click here to view the Vendor Contact List.

InfoSolutions®

InfoSolutions is an electronic health care information network. It allows providers to access more complete and timely medical information on all their patients and enables office management systems to retrieve provider and claims information electronically from Blue Cross. InfoSolutions facilitates the care and treatment of patients by solving the common problems of information exchange.

InfoSolutions has many features to help your practice become a leader in the delivery of efficient and cost effective medicine. Following is a description of these features:

·

Time spent looking for or ordering medical records is eliminated.

·

Confidentiality of a patient's medical record is enhanced within InfoSolutions through extensive levels of security with access provided only to authorized personnel.

·

Through our e-Practice Management System:

 

·

Claims status, patient eligibility, and claims history for Blue Cross and Medicare patients is available online.

 

·

Audit trails are available within 48 hours of submission.

 

·

Patient information is available to initiate effective preventive care procedures.

Toll-Free Provider Customer Service Line

Blue Cross and Blue Shield of Alabama is offering you toll-free telephone access to dedicated Customer Service Representatives is your office will retrieve general patient account information electronically.

To take advantage of this service, you must be electronically connected to Blue Cross. If you do not have an electronic connection to Blue Cross, please contact your practice management vendor.

Once you are electronically connected, complete and return the Customer Service Toll-Free Access Provider Agreement to the address below:

Blue Cross and Blue Shield of Alabama
Attn: Customer Service Toll-Free Access Agreement
Post Office Box 360040
Birmingham, Alabama 35236-0040

Provider Data Maintenance

Accurate and complete information is important for both providers and Blue Cross and Blue Shield of Alabama. Blue Cross and Blue Shield of Alabama's provider file is utilized for remittance payments, directory listings, Internal Revenue reporting, and publication mailings.

To change your tax identification number, you should request a new provider application by calling 205 220-7528.

Provider Change Notification
Updates to name, address, and provider specialty status must be submitted in writing on the provider’s/entity’s letterhead with the provider’s signature or by completing the Provider Change Notification. Be sure to sign your correspondence, and mail or fax it to the address below:
.

Blue Cross and Blue Shield of Alabama

Attention: Provider Data Maintenance

Post Office Box 12244

Birmingham, Alabama 35202-2244

Fax Number: 205 220-7463

Important Addresses

BellSouth Refunds and Adjustments

BellSouth Dedicated Service Center

Post Office Box 830279

Birmingham, Alabama 35283-0279

 

BellSouth Services

BellSouth Dedicated Service Center

Blue Cross and Blue Shield of Alabama

Post Office Box 830279

Birmingham, Alabama 35283-0279

 

Claims

Blue Cross and Blue Shield of Alabama

Post Office Box 2294

Birmingham, Alabama 35201-2294

 

Physical Therapy Appeals
Blue Cross and Blue Shield of Alabama
Post Office Box 362025
Birmingham, Alabama 35236

Correspondence

Blue Cross and Blue Shield of Alabama

Post Office Box 2294

Birmingham, Alabama 35201-2294

 

Federal Employees

Federal Employee Program (FEP)

Blue Cross and Blue Shield of Alabama

Post Office Box 10401

Birmingham, Alabama 35202-0401

 

FEP Refunds and Adjustments

FEP Dedicated Claims

Medical Records Department

Post Office Box 10401

Birmingham, Alabama 35202-0401

 

NASCO Refund Checks

Blue Cross and Blue Shield of Alabama

Post Office Box 10528

Birmingham, Alabama 35282-9012

 

Refunds and Adjustments

Blue Cross and Blue Shield of Alabama

450 Riverchase Parkway East

Birmingham, Alabama 35244-2858

 

"24-Hour Coverage" for Work-Related Injuries

Blue Cross and Blue Shield of Alabama

Attn: WRI Department

Post Office Box 361787

Birmingham, Alabama 35236-1787

 

ICD-9 Coding Manual and HCFA Common Procedure Coding System (HCPCS) (Including Tapes)

Medicode, Inc.

Med-Index Division

5225 Wiley Post Way Suite 500
Salt Lake City, Utah 84116-2889
1 800 678-8398

OR

HCFA and Local Level HCPCS Codes

Blue Cross and Blue Shield of Alabama

Attn: Network Services

450 Riverchase Parkway East

Birmingham, Alabama 35244

Special Telephone Numbers

Below is a list of helpful telephone numbers available for provider inquiries:

Provider Customer Service

205 988-2213

   

Network Data Operations

205 220-2533

   

Blue Cross and Blue Shield of Alabama Anti Fraud Hotline

1 800 824-4391

   

Provider Inquiry Voice Response Unit (VRU)

1 800 648-9807

 

205 987-4636

   

Unique Provider Identification Numbers (UPIN) Directories

205 985-0191

   

Provider Inquiry Department

Provider Telephone Representatives are available to answer your questions regarding patient eligibility and benefits, as well as claims status. The most immediate response can be achieved through the Voice Response Unit (VRU) or electronic practice management software.

Provider Inquiry Voice Response Unit (VRU)

While Blue Cross and Blue Shield of Alabama has telephone representatives dedicated to assisting your office with detailed claims and patient benefit information, the VRU can provide you with a patient's basic eligibility and benefits and claims status information without having to speak with a representative. Accessing information through the VRU is very efficient and your call will connect directly into the unit for the most immediate response.

Examples of information available through the VRU include patient eligibility, copayment amounts, deductibles and claims status, plus much more. You may also order copies of your remittance through the VRU.

To access the VRU you will need: your plan code (510 for Alabama providers) and provider number, the patient's contract number, and the date of birth and sex of the patient.

The VRU can be accessed toll-free at 1 800 648-9807 or locally at 205 987-4636.

Provider News and Updates

Blue Cross and Blue Shield of Alabama communicates with providers through many publications created solely for providers, including this manual. All of these communication pieces are available through our Web page (http://www.bcbsal.org/). Here are some instructions on how to locate these publications and how to utilize the search engine:

1.

Key http://www.bcbsal.org/ on your address line.

2.

Choose Providers.

3.

Choose Provider News.

You can either go directly to the publication that you need or choose Search located at the beginning of each list.

If you choose Search:

1.

Type in your topic (alpha and/or numeric).

2.

Choose to search all publications or choose to search only one.

You should receive a list of publication issues that contain your topic. Click on the issue that you are interested in. For the large publications, you may want to use the Edit, Find function provided by your browser.

It is imperative that you take the time to read through the publications for information that may pertain to your practice. Many times you will receive only one notification of important changes.

The publications available are:

ProviderFacts

This quarterly magazine contains information pertaining to Blue Cross and Blue Shield of Alabama's regular business such as claims filing, coverage, and network news.

Special Bulletins

These bulletins are done on an as needed basis and pertain to Blue Cross regular business issues.

Medicare Focus

This monthly magazine contains Medicare issues such as claims filing and coverage.

Medicare Special Bulletins

These bulletins are done on an as needed basis and pertain to Medicare issues.

EMC Update

This quarterly magazine contains updates and news related to electronic claims, remittances, audit trails, InfoSolutions, etc.

Identification Cards

Identification cards for Blue Cross and Blue Shield of Alabama members contain information you need for filing claims. Be sure to list the patient's contract number exactly as it appears on the card, including any alphabetic prefixes. Many Blue Cross members have an XAA prefix with their contract number.

Click here to view a sample identification card.

BlueCard PPO Program

Members with out-of-Alabama Blue Cross and Blue Shield coverage will be processed through the BlueCard Preferred Provider Organization (PPO) Program. The BlueCard PPO Program was developed in order to improve administrative services and timely processing of claims for providers in all Blue Cross and Blue Shield Plan areas. This national network allows
Blue Cross Plans to coordinate the local processing of claims for out-of-area and national account members.

Claims may be filed electronically and must show the member's correct prefix. Providers should ensure that the correct prefix and member numbers are shown on the claims.

The BlueCard PPO Program involves the electronic transmission of claims and payment information between the local Blue Cross Plan and the Blue Cross Plan with which the member has contracted. The BlueCard PPO Program offers these advantages:

·

Providers can send claims for Blue Cross members with identification cards from Plans other than Alabama to Blue Cross and Blue Shield of Alabama.

·

The BlueCard PPO Program reduces the need for providers to deal with the many different Blue Cross Plans across the nation.

·

Blue Cross and Blue Shield of Alabama encourages the use of electronic filing, which traditionally has not been possible for out-of-area claims.

·

Timely payments from Blue Cross and Blue Shield of Alabama in a familiar remittance format.

·

Identification cards with the PPO suitcase are treated as an Alabama Preferred Contract subject to the fee schedule and other provisions of the contract. The only exception is the precertification process which is waived.

Click here to view a sample identification card.

Completion of the Blue Cross and Blue Shield of Alabama Provider’s Claim Form

On the following page is a copy of the CL-4 claim form. Certain items that need clarification are indicated below:

1a.

List the identification number as shown on the patient's identification card.

   

5.

Be sure to list the complete address, including the zip code and the telephone number.

   

9 a, b, c, d

Please complete if the patient is covered by another insurance policy.

   

10.

Check the "Yes" or "No" block when applicable.

   

17.

If you are billing for a service as a result of a referral, indicate the name and unique provider identification number (UPIN) of the referring physician.

   

21.

List each ICD-9 diagnosis code for which services were rendered.

   

24A.

Enter month, day, and year (including century) for each service rendered. If like services are rendered over consecutive dates of service, enter one date of service per line. “Spanning dates” are not accepted.

   

24B.

Insert a one-digit place of service code to indicate where the physician treated the patient.

   

24C.

Insert a one-digit type of service code.

   

24D.

Use the applicable five-digit Physicians’ Current Procedural Terminology (CPT) or Health Care Financing Administration Common Procedure Coding System (HCPCS) procedure code to describe the service rendered. Any modifiers applicable should be noted here.

   

24G.

Please indicate the number of services rendered, as this may affect claims payment.

   

27.

Payment for Preferred Physical Therapy services will be made directly to the provider.

   

31.

The provider of services must sign and date the claim (actual or stamped) or the claim must be signed by an authorized representative as prearranged with Blue Cross and Blue Shield of Alabama.

   

33.

You may order preprinted claim forms with this information. The PIN is the provider number. Example 51000009ABC

Time Limits for Filing Claims

All groups have time limitations for submission of claims. For most groups, claims must be filed within 24 months of the date of service.

Some exceptions are (but not limited to):

·

State of Alabama (group number 13000) and PEEHIP (group number 14000) claims must be received within one year of the date of service.

·

The Federal Employee Program (FEP) (group number 53533) claims must be received by December 31 of the following calendar year of the date of service (e.g., a claim for January 12, 1999, must be filed by December 31, 2000).

·

BellSouth claims must be received within one year of the date of service.

NOTE: You have 60 days to request a reconsideration of a BellSouth claim. There are other exceptions. If you are not sure of a time limit, you may call the appropriate Provider Inquiry area.

Click here to view a sample HCFA-1500/CL-4 claim form.

Procedure Codes

Procedure coding is a uniform method of accurately describing the type of service rendered. The complete procedure coding structure consists of all three levels of codes: (1) Physicians' Current Procedural Terminology Fourth Edition (CPT-4) codes; (2) HCFA Common Procedure Coding System (HCPCS) codes; and (3) Local Level codes.

CPT-4 is a listing of descriptive terms and identifying codes for reporting medical services and procedures performed by physicians. The CPT-4 is published by the American Medical Association and is updated yearly. The address for ordering new CPT-4 books is listed in the "Important Address" section of this manual.

Type of Service Codes

0

Assistant Surgeon

2

Surgery

3

Maternity

4

Anesthesia

5

X-Ray--Diagnostic (total fee)

6

Medical Care

7

Dental Care

8

Clinical Laboratory or Pathology (total fee)

9

Consultation

A

Emergency Medical Care

B

Concurrent Care

C

Psychiatric Care

D

Physical Therapy/Medicine (Including Speech Therapy)

E

X-ray—Therapeutic

F

Ambulance Service

G

Physical Accessories (Purchase)

 

Durable Medical Equipment

 

Medical Surgical Supplies

 

Optical Accessories

 

Orthopedic Accessories

 

Prosthetic Devices

   

H

Physical Accessories (Rental)

 

Durable Medical Equipment

 

Medical Surgical Supplies

 

Optical Accessories

 

Orthopedic Accessories

 

Prosthetic Devices

I

Dental Surgery

J

Home Care Program Services

M

Vision Care

N

Emergency Accident Care

P

Professional Component (Radiology and Pathology)

Q

Chemotherapy (antineoplastics)

R

Donor Surgery and Related Services

T

Radioimmunoassay (R.I.A) or Competitive Protein Binding Analysis

U

Supplemental Accident

V

Hearing Care

W

Second Opinion Consultation/Surgery

X

Alcohol/Rehabilitation

Z

Portable X-ray—Technical

*

Hospice Care

@

Private Duty Nursing

Place of Service Codes

1

Hospital as Inpatient

2

Hospital as Outpatient

3

Physical Therapist’s Office

4

Patient's Home

5

Day Care Facility--Psychiatric

6

Night Care Facility--Psychiatric

7

Nursing Home/Domiciliary Facility

8

Extended Care Facility/Skilled Nursing Facility

9

Ambulance

A

Independent (lay owned) Laboratory

B

Other Medical/Surgical Facility (non-psychiatric), i.e., freestanding ambulatory surgical facility

C

Dental Office

D

Residential Substance Abuse Treatment Facility

E

Outpatient Substance Abuse Treatment Facility

F

Psychiatric Day Care as inpatient in psychiatric or general hospital, community mental health clinic or a community clinic

H

Freestanding Hospice Facility

Diagnosis Codes

An International Classification of Diseases 9th Revision Clinical Modification (ICD-9-CM) code must be used to identify each patient's diagnosis or nature of illness or injury. A written diagnosis is not required when the code is given. Diagnosis codes are very important in making benefit determinations. They are used to evaluate whether or not services are medically necessary, if a condition is pre-existing, if Workers' Compensation is applicable, and for screening medical emergencies. Use the most specific 3, 4, or 5-digit code for that diagnosis.

Adding a zero to the right of a three-digit code to make it five digits can make the code invalid or change the intended meaning. Include five digits if the ICD-9 code book indicates that the use of the extra digit is required to more specifically describe the diagnosis.

The 800-900 series of diagnosis codes are for identifying current injuries due to an accident. If you are not providing a service for a current injury (i.e., injury that has occurred and required treatment within 90 days), then the diagnosis code should be selected from another section in the ICD-9-CM code book.

Remittance Notice

Blue Cross and Blue Shield of Alabama’s remittance checks are mailed each Thursday and include claims processed in the previous week (Monday through Friday).

A remittance statement will accompany each check identifying the claims processed. Should a claim be rejected, it will be indicated on the remittance statement by a rejection code. The rejection codes will be given at the end of each remittance.

Explanation of Columns
"Disp Code" Column: Special instructions explaining how a claim was processed
"Non-Covered Charges" Column: Total rejections
"Patient Payable Deduct" Column: Any amounts credited toward the Major Medical or Federal Employee deductible and due by the patient
"Patient Payable Copay" Column: Copayment on Preferred Care services; coinsurance amounts for Major Medical services (e.g., 10%, 20%, 50%); the coinsurance amounts owed by patients with other coverage (e.g., retired State employees)
"Non Allowed" Column: mount over the physical therapist fee schedule; any amount over the usual, customary and reasonable fee

Note: This column does not always indicate a write-off amount. Refer to your disposition codes ("Disp Code") column for information on why an amount is shown in this column.

"Other Coverage" Column: The amount Medicare paid on assigned claims only (For non-assigned claims, "O.OON" will show.); any amount another Blue Cross contract paid; any amount another insurance company paid (if we know that information)

Overpayments

When a provider finds an overpayment on his/her remittance, the provider should deposit the check whether it is a complete or partial overpayment. The Voluntary Check Return Transmittal should be utilized to notify Blue Cross and Blue Shield of Alabama of the overpayment. Complete the form and attach a check for the amount of the overpayment only or choose Deduct and the amount will be deducted from a future remittance.

The Voluntary Check Return Transmittal will save time for providers and Blue Cross by reducing the need for reissued checks. Another important benefit of utilizing the Voluntary Check Return Transmittal is that it will ensure that the provider's Information Return Form 1099 for medical payments is correct. The provider's check serves as support for deduction or reduction of revenues.

Voluntary Check Return Transmittal
With the help of providers and the American Medical Association, Blue Cross and Blue Shield of Alabama has created the Voluntary Check Return Transmittal that will improve the process of correcting overpayments. Below is an explanation of how and when to use the form:

·

Use the form to accompany any unrequested overpayments.

·

Use one form per member. More than one claim for a member may be included on a form.

·

Several forms may be combined on one check.

·

Providers can print a copy of the form from our Web page (http://www.bcbsal.org/); copy the form on page 33; or call our Provider Inquiry Department at 205 988-2213. If ordering through Provider Inquiry, the stock number is ACT-110.

Provider Payments to Blue Cross and Blue Shield of Alabama
Whenever making a check payable to Blue Cross and Blue Shield of Alabama, attach a copy of the invoice or the request for payment to your check.

In cases of refunds of overpayments applicable to a specific claim, identify on the face of your check the name of the patient, the contract number and the date of service.

By taking these actions you can assure that proper credit will be applied and avoid confusing situations where Blue Cross and Blue Shield of Alabama is unable to determine which account to properly credit.

Click here to view a sample of the Voluntary Check Return Transmittal.