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Claims Inventory Update: What BCBSNC Is Doing to Address Your Feedback

We are listening and responding to the feedback we’ve received from the provider community about the claims processing issues you’ve experienced. We are making progress on addressing these reported issues.  For example, our commercial, State Health Plan, and Federal Employee Program claims processing levels are returning to normal.  Our automatic claims processing rate is back up to 92 percent, which is our historical norm for commercial claims, and we expect to have the current claims backlog cleared out within the next 30 to 60 days.

We believe we are on top of the changes that created these claims processing issues, which included:

  • Claims processing system upgrades and replacement of older systems that resulted in more manual work, decreased automation, as well as impacted productivity and claim-related workflows.

 

  • After the Federal Employee Program claims payment system was migrated to a new platform in October 2013, we experienced delays in claims processing for certain claim types.

 

  • Significant challenges associated with the roll-out of the Affordable Care Act and the federal Marketplace had a domino effect on our operational areas. Last-minute changes from the federal government — such as the recent extension of time to complete enrollment — exacerbated these challenges.

What We’re Doing Now

We’re committed to processing your claims as quickly as possible, including addressing our backlog.  In order to better assist you, we have created an escalation process to address your concerns about aged claims. If you have outstanding claims greater than 60 days, and you've not already spoken to one of our provider specialists, call us at 1-800-214-4844 for assistance.

Here are some of the ways we’re reducing our cycle time for processing claims: 

  • Commercial Claims
    • System enhancements put in place to eliminate many of the claims processing issues.
    • Focused on working through aged claims of 30 days or older.
    • Deployed automation to help clear out duplicate claims in the system.

 

  • State Health Plan Claims
    • Developed a claims inventory reduction plan in January that resulted in a 40 percent reduction in claims inventory over an eight-week period.
    • Claims inventory volumes and processing turnaround times are approaching the levels that were consistently maintained prior to the system upgrades.

 

  • Federal Employee Program Claims
    • Implemented a number of system enhancements and remediation steps to address many of the claims processing issues.  However, a claims payment backlog still remains, and additional post-implementation system enhancements and related efforts to resolve these payment issues are underway.  We are working to process aged claims first.

For Blue MedicareSM Claims

While Blue Medicare claims have not been significantly affected by system upgrades, we are monitoring our metrics to ensure we meet our internal standards and CMS-related expectations.  To prevent delays, we have:

  • Evaluated certain claim suspends and identified process improvements that are being implemented.
  • Reviewed issues that generate a high volume of incomplete claims and outlined opportunities for provider education and collaboration.

How to Help Ensure Your Claims Are Processed As Quickly as Possible

In order for us to continue to move forward in improving our claims processing cycle times, here are some ways you can help:

  • Please do not submit duplicate claims, as they increase our inventory and impact our timeliness in processing your claims.
  • Make sure claims are complete and accurately coded before submitting them for processing.
  • Include NPI numbers, Medicare number as appropriate, and your tax ID on the claim.
  • Keep your contact information, including address and phone number, up-to-date with us.
  • Submit any requested or required information in a timely manner.
  • Do not send medical records with claims unless we have specifically requested them.
  • Check claims status on Blue eSM (Health Trio link for Blue Medicare claims) prior to calling customer service or resubmitting the claim.  When checking claims status on Blue e, please note the “Pended Status,” as that will indicate if the claim is fully processed or not at this time. 

We are in a new health care environment in which government, market and industry changes will continue to create changes that impact us all. We are committed to working cooperatively with the North Carolina provider community to address these issues and their impact on our day-to-day interactions with each other, our collective and respective systems, and on your patients/our members.

We are committed to increasing our dialogue and transparency through more regular communications to the provider community in the future.