Skip Navigation

Back to Index

Claims Inventory Update as of July 15, 2014

We wanted to provide you with an update to the information we shared with you in May regarding our progress addressing our claims inventory. Overall claims inventories, including claims pending for clinical reviews, were significantly reduced and newly submitted claims are being processed faster. Here are the updates for each of our major lines of business as of mid-July:

  • Commercial Claims
    • Inventories have stabilized for our ASO and Inter-Plan Program business. We continue to focus resources on reducing aged inventory of insured business claims, medical review, corrected claims, and duplicate claims.
    • Added additional staff to further reduce corrected claims inventory for insured business.
    • Reduced duplicate claims volume by 50 percent. Automation deployed to more quickly work duplicate claims. Please do not submit duplicate claims, as it will result in processing delays.
    • Currently, some delinquent member accounts have resulted in approximately 25 percent of unprocessed claims to suspend until additional premium monies are received. Under the Affordable Care Act, individual insurance policies purchased through the Exchange and that receive an advanced premium tax credit are eligible for a three-month grace period for premium payments. Please note we are responsible for paying all claims incurred by these Exchange members during the first 30 days of delinquency, and we do not seek reimbursement for these claims if the member’s policy is terminated.
    • System and process enhancements are being implemented to address current delays in the processing of some claims requiring authorizations, which are resulting from a recent system migration in our Care Management area.


  • State Health Plan Claims
    • Achieved a 60 percent reduction in inventory of aged claims older than 30 days continuing our focus to resolve the remaining aged claims inventory.
    • Duplicate claims inventory reduced by an additional 35 percent over the past month.
    • Total claims inventory reduced by another 30 percent during the past month, which returned us to normal inventory levels for the State Health Plan.


  • Federal Employee Program Claims
    • Reduced inventory of aged claims 30 days or older by 85 percent. Working to achieve further reductions, but close to the acceptable range for aged claim inventory.
    • Implemented an additional system enhancement to improve the timeliness of inpatient claims with DRG pricing.
    • Future system and reporting enhancements are being planned to improve claims tracking and reduce manual work.

For Blue MedicareSM Claims

There was significant progress to address our Blue Medicare claims inventory as follows:

  • Reduced overall claims inventory by 75 percent since May 1.
  • Reduced aged claims inventory (30 days or older) by 90 percent since April.
  • Completed project resulting from process change to return incomplete claims to providers for resubmission. To avoid delays in claim processing and/or unnecessary mailbacks going forward, providers should file claims with complete and accurate data.

As a reminder, from November 2013 through mid-March 2014, our Blue Medicare claims department phased in a process change in which we stopped automatically denying certain claims and began manually reviewing them.  For these claims we now:

  • Suspend them for manual review.
  • Determine if additional information is needed from the provider.  If no additional information is needed, the claim is manually processed.  If additional information is needed, we will make three attempts to contact the rendering provider by phone, then one attempt by letter, to obtain the necessary information to complete processing of the claim.
  • If we are unable to get the necessary information after these four contact attempts, we will reject the claim as incomplete and/or invalid and return it to the provider to resubmit with the required information.

Blue Medicare continues to focus on identifying and resolving claims processing issues expeditiously.

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.

In order to better assist you, an escalation process is in place 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.