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EOP Enhancement

You may have noticed that we’ve added a new field to the BCBSNC EOP (explanation of payment).

The new field was created to assist with tracking claims adjusted as a result of BCBSNC offsetting overpayments. Now when a claim is adjusted and results in a negative balance, the newly created field will display text reading Balance Forward (beginning balance amount) and/or any Ending Balance (ending balance amount) for the entire remittance being reported. As an example:

Example of a claim adjustment for an overpayment in the amount of $75.00 dollars

Patient’s Name ID Number Dates of Service Patient Number Medical Rec Number Place
Type of Service PC/Days Prov ID Billed Charges Contracted
Charges
Disallowed Amount Deductible Amount Copay/Coins Amount Remaining
Mbr Expense
Remark Code Amount
Paid
SUBSCRIBER Mary   W12345678901                  11/29/2006                             11/29/2006                              MBS123456                               OFFICE
WELLNESS         99355                12345              -85.00             -75.00            -10.00                -0.00               -25.00                -0.00              E32                -50.00
                                                                           11/29/2006                             11/29/2006                              MBS123456                               OFFICE
LAB                    87210                12345               -25.00            -20.00              -5.00                -0.00                -0.00                -0.00                E32                -20.00
HMO-BLUE CARE                        CLAIM                0112220601930              EFT BATCH #: 070012345                                     CLAIM TOTAL                -75.00

The negative balance created by offsetting the overpayment would display on the EOP as an Ending Balance of negative -75.00 dollars.

Ending Balance -75.00

This new field does not change the current process for requesting refunds. In the event that we notice an overpayment in excess of the member’s benefits, BCBSNC will request in writing that a refund in the amount of the overpayment be returned. We ask that providers return to BCBSNC the benefit overpayment as soon as possible; however, if the refund is not received within 45 days of the written request, we may recover undisputed overpayment amounts by offsetting future claims payments. In the event that an overpayment is being collected by offset, any amount remaining as uncollected will display in the new EOP field as the Ending Balance (the balance remaining as uncollected).

As example, if a claim was adjusted for an overpayment in the amount of $85.00 dollars and 45 days had past since BCBSNC sent a refund request letter for the $85.00 overpayment to be refunded, the next claim that processed may have the negative balance offset against the eligible benefit payment.

Patient’s Name ID Number Dates of Service Patient Number Medical Rec Number Place
Type of Service PC/Days Prov ID Billed Charges Contracted
Charges
Disallowed Amount Deductible Amount Copay/Coins Amount Remaining
Mbr Expense
Remark Code Amount
Paid
SUBSCRIBER Mary   W12345678901                  11/29/2006                             11/29/2006                              MBS123456                               OFFICE
WELLNESS         99355                12345             85.00                 75.00            10.00                -0.00               25.00                -0.00                 E32                -50.00
                                                                           11/29/2006                             11/29/2006                              MBS123456                               OFFICE
LAB                    87210                12345             25.00                 20.00             5.00                -0.00                -0.00                -0.00                  E32                -20.00
HMO-BLUE CARE                        CLAIM                0112220601930              EFT BATCH #: 070012345                                     CLAIM TOTAL                -75.00

The negative Ending Balance from this example is -10.00 dollars because $75.00 dollars of the eligible payment was withheld, leaving $10.00 dollars remaining of the $85.00 dollar overpayment amount. This means that a -10.00 dollar negative balance remains and is listed on the EOP as the Ending Balance

Ending Balance -10.00

We hope that this new field on the EOP will help to streamline processes within your office for tracking claims adjustment in the event an adjustment, due to an overpayment, is ever initiated by BCBSNC. Please note that the new field will appear on EOP’s for claims processed on our Power MHS claims processing and payment system as of April 12, 2008.

Providers with questions about the new EOP field should contact their local Network Management office.