BlueCard Claim Enhancements for Medicare Statutorily Excluded Services
Since January 1, 2006, all Blue Plans, including Blue Cross and Blue Shield of North Carolina (BCBSNC), are required to process Medicare-crossover claims for services covered under Medigap and Medicare Supplemental products through the Centers for Medicare & Medicaid Services (CMS). This has resulted in automatic submission of Medicare claims to the Blue Plan secondary payer eliminating the need for the provider’s office or billing service to submit an additional claim to the secondary carrier. Additionally, this has also allowed Medicare-crossover claims to be processed in the same manner nationwide.
Beginning in October, the following Medicare-crossover servicing updates will be in place for all Blue Plans to more accurately price and process these claims:
· Starting October 13, 2013, providers should submit only those statutorily excluded services by Medicare (i.e., home infusion therapy and hearing aids) to BCBSNC with a GY modifier on each line for the service that is excluded or not covered by Medicare. The GY modifier should be used to indicate that the item or service is statutorily excluded. This will allow BCBSNC to apply the contracted rate with the provider to accurately process the claim according to the member’s benefits. Also, by submitting statutorily excluded services with a GY modifier directly to BCBSNC, you will receive payment for these services in a timelier manner.
· Additionally, when a provider submits a claim to Medicare for services statutorily excluded and not covered by Medicare, but the member has benefits for those services, providers will receive notification via either a paper or electronic remittance advice or letter from the Blue Plan with instructions to submit those statutorily excluded services directly to BCBSNC. Instructions will be similar to the messages below for each format:
· For paper remittances: “This service is excluded or not covered under Medicare. However, the service may be eligible for benefits under other coverage. Please submit this service to your local Plan.”
· For electronic remittance advice: The following HIPAA claim adjustment reason codes and remark codes will be included on the 835 responses:
· Claim Adjustment Reason Code (CARC) 109: “Claim not covered by this payor/contractor.”
· Remittance Advice Remark Code (RARC) N837: “Alert: submit this claim to the patient’s other insurer for potential payment of supplemental benefits. We did not forward the claim information.”
· Group Code: OA
Commonly Asked Questions:
Where do I put the GY modifier on the claim?
The GY modifier should be used with the specific, appropriate HCPCS code when one is available. In cases where there is not a specific procedure code available to describe services, a “not otherwise classified code” (NOC) must be used with the GY modifier.
The GY modifier is located in the line-level procedure code modifier field(s), and the modifier can be:
· Present position 1, 2, 3 or 4
· On the paper 1500 form, the GY modifier can be found in field 24D
· On the paper UB04 form, the GY modifier can be found in field 44
· On the 837P, the GY modifier is found at level 2400, Service Line Loop in SV101-3, SV101-4, SV101-5 or SV101-6
· On the 8371, the GY modifier is found at level 2400, Service Line Loop in SV202-3, SV202-4, SV202-5 or SV202-6
Who do I contact if I have questions?
If you have questions, please call BlueCard® Customer Service at 1-800-487-5522.
Want to learn more about the Medicare-crossover process?
Note: The following information was shared with providers in September 2012 in an article titled, Duplicate Claims Handling for Medicare Crossover. The article is accessible via the Archives section of the provider portal’s Important News page.
When a Medicare claim has crossed over, providers are asked to wait 30 calendar days from the Medicare remittance date before submitting the claim to BCBSNC.
Providers should continue to submit Medicare-covered services directly to Medicare. Even if Medicare benefits may exhaust or have exhausted, continue to submit claims to Medicare to allow for the crossover process to occur and for the member’s benefit policy to be applied.
Medicare primary claims, including those with Medicare exhausted services that have crossed over and are received within 30 calendar days of the Medicare remittance date or with no Medicare remittance date, will be returned by BCBSNC.
How do I submit Medicare primary / Blue Plan secondary claims?
· For members with Medicare primary coverage and Blue Plan secondary coverage, submit claims to your Medicare intermediary and/or Medicare carrier.
· When submitting the claim, it is essential that you enter the correct Blue Plan name as the secondary carrier. This may be different from BCBSNC. Check the member’s ID card for additional verification.
· Be certain to include the alpha prefix as part of the member identification number. The member ID number of the Blue Plan that is secondary should be included too. The member’s ID will include the alpha prefix in the first three positions. The alpha prefix is critical for confirming membership and coverage, as well as key to facilitating prompt payment of claims.
When you receive the remittance advice from the Medicare intermediary, look to see if the claim has automatically crossed over or forwarded to the Blue Plan:
· If the remittance indicates that the claim was crossed over, this means that Medicare has forwarded the claim on your behalf to the appropriate Blue Plan and the claim is in process. There is no need to resubmit that claim to BCBSNC.
· If the remittance indicates that the claim was not crossed over, submit the claim to BCBSNC with the Medicare remittance advice.
· In some cases, the member ID card may contain a COBA ID number. If so, be sure to include that number on your claim.
· For claim status inquiries, contact BlueCard® Customer Service at 1.800.487.5522.
When should I expect to receive payment?
The claims you submit to the Medicare intermediary will be crossed over to the Blue Plan only after they are processed first by the Medicare intermediary. The Medicare intermediary process takes approximately 14 business days. This means that the Medicare intermediary will be releasing the claim to the Blue Plan for processing about the same time you receive the Medicare remittance advice. As a result, upon receipt of the remittance advice from Medicare, it may take up to 30 additional business days for you to receive payment or instructions from the Blue Plan.
What should I do in the meantime?
If you submitted the claim to the Medicare intermediary/carrier and haven’t received a response to your initial claim submission, do not automatically submit another claim. Rather, you should:
· Review the automated resubmission cycle on your claim system.
· Wait 30 calendar days from receipt of the Medicare remittance advice.
· Check claims status before resubmitting.
Sending another claim, or having your billing agency resubmit claims automatically, actually slows down the claim payment process and creates confusion for the member.