When submitting claims, transfer the member’s identification (ID) number exactly as printed on the ID card. Remember to include the leading three-character prefix and enter it in the appropriate field on the claim form.
When completing the CMS-1500 form, note the following:
HIPAA's Administration Simplification provision requires a standard unique identifier for each covered healthcare provider (those that transmit healthcare information in an electronic form in connection with HIPAA-standard claim transactions). The NPI replaces all proprietary (payer-issued) provider identifiers, including Medicare ID numbers (UPINs). It doesn't replace your tax ID number (TIN) or Drug Enforcement Administration (DEA) number. TINs are still a required element for claims. Electronic claims without a TIN are rejected as incomplete. If you need more information about the NPI mandate, Medicare timelines, and/or the enumeration process, visit the CMS website.
You can submit claims daily, weekly, or monthly. The earlier you submit claims, the earlier we process them. Ideally, we'd like you to submit claims within 60 calendar days of the covered services, but no later than 365 calendar days. For most plans, we'll deny claims received more than 12 months after the date of service with no member responsibility. Refer to your contract for further claims submission information.
If you are unable to submit claims electronically, you can submit paper claims on CMS-1500 or UB-04 forms. To speed claims processing, we use document imaging and optical character recognition (OCR) equipment to read your claims. To ensure that OCR reads your paper claims accurately:
Submitting a corrected claim may be necessary when the original claim was submitted with incomplete information (e.g., procedure code, date of service, diagnosis code). The preferred process for submitting corrected claims is to use the 837 transaction (for both professional and facility claims) using claim frequency code 7.
If submitting a corrected claim on paper, remember to:
Obtain Corrected Claim - Standard Cover Sheets at onehealthport.com in the administration simplication claims processing section, or under Forms on our provider website.
You can obtain the status of a claim:
A fragmented or split professional billing is defined as professional services rendered by the same provider for the same date of service and submitted on multiple professional claim forms.
Be sure to submit a paper or electronic CMS-1500 claim form that is complete and accurately filled out. Here are common reasons why claims suspend or reject:
Contact Customer Service with questions regarding claims processing, or send a copy of the voucher highlighting the claim in question and the inquiry reason. If we processed the original claim incorrectly, you do not need to rebill. The claim will be reprocessed and reflected on the payment voucher. You can reach Customer Service by calling 877-342-5258, option 2, or by calling the Customer Service phone number on the back of the member's ID card. Before discussing member claim information, the Customer Service representative must verify the identity of the caller.
If you are a clinic or hospital-based physician or other qualified healthcare provider, use a CMS-1500 (02-12) form for claims for professional services and supplies related to:
This includes claims for outpatient services and services performed by a hospital-based physician or other qualified healthcare provider.
Many offices assign their own account numbers to patients. To make tracking patient reimbursement easier, we can include these account numbers on our payment vouchers. Your account number can be included in box 26 (Patient's Account Number) of the CMS-1500 form whether you submit electronically or on paper. Note that some processing systems may have a limitation regarding the number of characters recognized.
The National Uniform Claim Committee (NUCC) has developed a 1500 Reference Instruction Manual detailing how to complete the claim form to help nationally standardize how the form is completed. Please refer to your electronic billing manual for specific formatting for electronic claims.
Our electronic claims process electronically separates and routes only valid claims for processing. Invalid claims are reported back to the provider with rejection details. There is no charge to healthcare providers who submit electronic claims directly to us.
If you submit your claims electronically, you may receive electronic remittance for the following:
Submit claims electronically for:
Remittance is available online-just let us know. Your office staff can then post this remittance manually or electronically (if your software has electronic posting capability).
To help you move from paper to electronic claims, follow these steps:
Electronic claims can be sent when we are the secondary insurance payer. If you bill your claims using the ANSI 837 electronic format, then you must include the Coordination of Benefits (COB) information from the primary coverage payer in your claim. COB information is allowed when the primary coverage is with a commercial payer; this generally excludes Medicare and FEP. If you are unsure how to submit secondary claims electronically, contact your practice management system vendor or contact an EDI representative at 800-435-2715.
Coordination of Benefits (COB) is a provision included in both member and physician and provider contracts. When two or more health plans cover a member, COB protects against double or over-payment. When we process a claim, we coordinate benefits if the member has other primary coverage from another carrier, our health plan, service plan, or government third-party payer. We'll coordinate the benefits of the members plan with those of other plans to make certain that the total payments from all plans aren't more than the total allowable expenses.
We abide by the following COB standards to determine which insurance plan pays first (primary carrier) and which pays second (secondary carrier). Briefly, these rules are as follows:
Some group contracts are not subject to state regulations may have unique COB rules that could change the order of liability.
Primary submission: Show all insurance information on the claim, and then submit the claim to the primary plan first.
Secondary submission: When submitting secondary claims to us, submit the primary processing information with the submission of the secondary claim.
When applicable, we will suspend payment until we determine which carrier is primary and which is secondary. We may send a questionnaire to the member regarding possible duplicate coverage. We need the member to promptly complete and return this questionnaire to process claims in a timely manner. When we are the primary carrier, we calculate and pay benefits routinely.
It is important to file a claim with all insurance companies to which the member subscribes. To ensure prompt and accurate payment when Premera is the secondary carrier, we encourage you to send the secondary claims with the primary processing information as soon as you receive it.
If we do not receive the EOB, and are unable to obtain the primary payment information by phone, the claim will be denied with a request for a copy of the primary EOB before processing can be completed. If you have questions about COB, contact Customer Service by calling the phone number on the back of the member's ID card.
Subrogation permits the plan to recover payments when the negligence or wrongdoing of another causes a member personal illness or injury. A subrogation provision is included in both member and physician/provider contracts. In third-party cases, this provision permits the plan to recover the medical bill costs on behalf of the member.
The member's benefit program contains special provisions for benefits when an injury or condition is:
An onset date should be recorded on all accident-related claims. The claim(s) will suspend and a processor will review to determine whether to send an Incident Questionnaire (IQ) to the member. (The IQ is available in the Provider Library under Forms. You can print and assist the member in completing the form, but it's important to review the instructions included with the form because the patient must complete the form and then sign it.) If the member does not return the IQ within the specified timeframe, we'll l deny all related claim(s). Once the IQ is returned, all claims are reviewed and processed based on the information supplied. The member or provider can submit the completed IQ using one of the following methods:
The member may contact Customer Service (the number is on the back of the ID card) to update IQ information over the phone. If all pertinent information is obtained, the claim(s) will then be processed according to the member's contract benefits. If we need additional information for subrogation determine to pay or deny, the IQ will either be sent back to the member requesting the information, or subrogation will make two calls within five days of receiving the IQ. If member does not return the call, claims will be denied until information is received. If member returns the call and the information is obtained, claims will be processed.
We will send the member an IQ if the claim(s) is potentially accident-related. When the member completes and returns the IQ form to Calypso Subrogation department, a representative will screen the document to determine if another party is responsible for processing claims prior to the health carrier stepping in. This review is necessary to determine whether the claim(s) should be covered by a first-party carrier (e.g., PIP, Med Pay or similar coverage - homeowners or a commercial medical premise policy).
Benefits are not available through us until the first-party carrier has exhausted, denied, or stopped paying due to its policy limits. Once we have received a payment ledger from the first-party carrier(s) showing where they paid out their limits (with dates of services, provider names, total charges, total paid, etc.), claims will be processed accordingly and under the terms of our subscriber's contract. If the IQ states that there is no first-party coverage(s) available, but there is a third-party that is responsible for the incident, we will process all related claims based on the member's contract with us until all parties are ready to negotiate a settlement for possible reimbursement.
Workers' Compensation will pay when the member's employer is liable to pay medical bills resulting from illness or injury arising out of, or in, the scope of employment. All of our contracts exclude coverage for care covered under the Workers' Compensation Act.
Claims submitted that indicate possible Workers' Compensation illness or injuries are investigated. We send the member a questionnaire requesting information to determine if benefits are available. If we do not receive a response within the specified period, the claim(s) is denied pending further information. If the information received indicates an on-the-job illness or injury, both the member and physician/provider will receive a denial that states the Premera contract excludes work-related conditions. If Workers' Compensation denies payment of such claims, Premera will pay according to the subscriber's contract benefits after receiving a copy of a valid denial.
In some contracts, we use a RBRVS methodology, developed by CMS, to calculate its fee-for-service fee schedule. RBRVS is a method of reimbursement that determines allowable fee amounts based on established unit values as set norms for various medical and surgical procedures, and further based on weights assigned to each procedure code. These weights are then multiplied by the dollar conversion factor we publish. The conversion factor represents the dollar value of each relative value unit (RVU). When the conversion factor is multiplied by the total RVUs, it will yield the reimbursement rate for the specific service (or code).
There are three separate components that affect the value of each medical service or procedure:
RVUs are assigned to each of these components. CMS also uses RVUs to allocate dollar values to each CPT or HCPCS code. For more information about RBRVS methodology visit the CMS website at cms.gov/physicianfeesched.
For services not listed in the RBRVS published annually in the Federal Register, we use Optum's Essential RBRVS (previously known as Ingenix Essential RBRVS and St. Anthony's Complete RBRVS).
We use an automated processing system to adjudicate claims. When processing claims, the system:
Actual payment is subject to our fee schedule and payment policies; to a member’s eligibility, coverage, and benefit limits at the time of service; and to claims adjudication edits common to the industry.
We regularly update (at least quarterly) our claims editing software to keep pace with changes in medical technology, as well as CPT codes, HCPCS codes, and ICD-10-CM/PCS Diagnosis and Procedure code changes, standards, and complexities. This software evaluates billing information and coding accuracy on submitted claims and assists in achieving consistent, accurate, and timely processing of physician and provider payments.
Our Claims Editor What If Tool allows you to enter a combination of codes that you may wish to bill and receive an informational description of how our claims editing software generally edits the code combination submitted. The description provided by the What If Tool is based solely on the information provided and does not take into account any other information such as claims history, eligibility, benefit, pricing deductible, or other member or group specific information. In addition, use of the What If Tool isn’t a guarantee of payment.
Physicians and other healthcare providers receive an Explanation of Payment (EOP), which describes our determination of the payment for services. See the following pages for an explanation of the EOP fields and a description of codes and messages.
The most commonly occurring codes and messages are listed below. A comprehensive list is posted in the Library under Reference Info.
Our Provider Billing Integrity Oversight Committee reviews proposals for new payment policies and updates to our policies. Physicians and providers may submit a proposal to modify a payment policy. To do so, please submit the proposal in writing to your assigned Provider Network Executive (PNE) or Provider Network Associate (PNA).
We follow industry standard coding recommendations and guidelines from sources such as the CMS, CPT, and AMA, and other professional organizations and medical societies and colleges. National Correct Coding Initiative (NCCI) editing is followed when applicable. Any exceptions are documented as Payment Policies. It is only after we determine a member’s eligibility or coverage that payment policy applies. Payment policy:
You can find our payment policies on our website in the Library, under Reference Info. Always refer to the online branded versions of our payment policies to ensure to most current and accurate information.
Calypso, our affiliate, processes refunds and overpayment requests. When Calypso identifies an overpayment, they mail an Overpayment Notification letter with a request for the overpaid amount.
Sometimes an office returns a check to us that represents multiple claims because a portion (see Threshold below) of the payment may be incorrect. In these cases, please don't return the check to us. Instead, deposit the check, circle the claim in question on the Explanation of Payment (EOP) and include a short explanation as to why there was an overpayment. After these steps are completed, you can choose one of the following options to resolve the overpayment:
Calypso will apply the refund to the claim as soon as they receive the refund. If you require a written refund request before mailing the overpayment, contact Calypso directly at 800-364-2991. We do not request refunds for overpayments less than $25, but you may submit these voluntarily. (BlueCard will request refunds regardless of the dollar amount.) Refund total overpayment amounts within 60 days of initial notice to avoid having outstanding refund amounts offset against future payments.
We process your claims as soon as we receive them. We also apply the following prompt pay standards set by Washington's Office of the Insurance Commission to our claims adjudication process in order to:
If the standards are met, the regulation does not require interest for those individual claims paid outside of the 95 percent threshold.
A clean claim is one that has no defect or impropriety, including any lack of any required substantiating documentation, or particular circumstances requiring special treatment that prevents timely payments from being made on the claim. This includes any missing required substantiating documentation or particular circumstances requiring special treatment.
Clean Claim Exclusions
Claims may also be delayed during processing if:
If we fail to satisfy any of the above standards, commencing on the 31st day, we’ll pay interest at a 15 percent annual rate on the unpaid or un-denied clean claim. Interest will not be calculated on unclean claims regardless of how long it takes to process them.
Prompt Pay interest is currently calculated monthly for the previous month's paid claims. Payments are issued under a separate voucher and mailed to the address on the original claim. Included with the interest voucher is a summary report detailing the claims for which interest payments have been applied during that period.
There is a minimum threshold of $25 for monthly interest payments on delayed clean claims. An interest check is issued only for months in which the accumulated interest is equal to or greater than the minimum threshold of $25. Interest less than $25 will continue to accrue until it reaches that threshold or until December of each year. To help your office complete year-end accounting, each December we'll issue you a check for the accrued interest we owe you, even if the amount is below the threshold.
Contact the Prompt Pay Unit at 800-932-2883 for inquiries regarding the following:
If your organization is contracted with Premera, most practitioners must be credentialed, with the exception of hospital-based practitioners. Learn more about which practitioners need to be credentialed by viewing our credentialing matrix, located in our credentialing manual, available by request from Credentialing.Updates@premera.com.
Practitioners who aren’t credentialed may have their claims returned until they submit a complete credentialing application. Lack of credentialing can be grounds for termination from Premera’s network.
You can learn more about credentialing by visiting the provider section of our website
A Statement of Overpayment Recoveries (SORA) is included with an Explanation of Payment (EOP) when we've processed an overpayment recovery activity within a payment cycle. The SORA is generated when one of the following occurs during a payment cycle:
Physicians and providers have the right to appeal certain actions of ours. Our provider appeals process ensures that we address a complaint or an appeal in a fair and timely manner. Our process meets or exceeds the requirements set by the Office of the Insurance Commissioner.
The provider appeals process does not apply to FEP, BlueCard Home Claims, Medicare Supplement plans, or Medicare Advantage plans.
Important: You have the option to start the appeals process at the complaint or Level I Appeal stage; however, either stage must take place within 365 days of the our action that prompted the dispute.
You can submit a complaint about one of our actions (verbally or in writing) to one of our associates. You have 365 calendar days to submit a complaint following the action that prompted the complaint. Complaints received beyond the 365 day timeframe will not be reviewed and the appeals rights pertaining to the issue will be exhausted.
If we receive the complaint before the 365-day deadline, we review and issue a decision within 30 calendar days via letter or revised Explanation of Payment. You also receive information about how to submit a Level I Appeal if you disagree with the decision.
You can make a complaint verbally to Customer Service or in writing to Customer Service Correspondence. You can reach Customer Service by calling 800-722-4714, option 2. The plan mailing addresses are in the Contact Information section or available on our website under Contact Us.
A Level I Appeal is used to either:
If you already filed a complaint and are appealing its outcome, the Level I Appeal must be submitted within the same 365-day time period of the action that prompted the dispute. Only appeals received within this time period will be accepted for review. Appeals rights will be exhausted if not received within the required timeframe.
Modifications we make to your contract or to our policy or procedures are not subject to the appeal process unless we made it in violation of your contract or the law.
A Level I Appeal is used for both billing and non-billing issues. A billing issue is classified as a provider appeal because the issue directly impacts your write-off or payment amount. A non-billing issue is classified as a member appeal because the financial liability is that of the member, not the provider (please refer to Chapter 6). Here are examples:
A Level I Appeal must be submitted with complete supporting documentation that includes all of the following:
Incomplete appeal submissions are returned to the sender with a letter requesting information for review. The time period does not start until we receive a complete appeal. Once the submission is complete and if the issue is billing related, we review the request and issue a decision within 30 days, along with your right to submit a Level II Appeal if you are not satisfied with the outcome. If the issue isn't billing related, we review the request and issue a decision within 60 calendar days. Only a member can request a Level II Appeal for a non-billing issue, unless the member has completed a release to allow the provider to act as their Representative.
Level II appeals must be submitted in writing within 15 calendar days of the Level I appeal decision and can only pertain to a billing issue. If the Level II appeal is timely and complete, the appeal will be reviewed. We notify you in writing if the Level II appeal is not timely and your appeal rights will be exhausted. Once we accept your level II appeal, we will respond within 15 days in writing or a revised Explanation of Payment. We also provide information regarding mediation should you disagree with the decision.
You must request mediation in writing within 30 days after receiving the Level II appeals decision on a billing dispute. We notify you in writing if the request for mediation is not timely. If your request for mediation is timely, both parties must agree upon a mediator. The mediator consults with the parties, determines a process, and schedules the mediation. If we cannot resolve the matter through non-binding mediation, either one of us may institute an action in any Superior Court of competent jurisdiction. The mediator's fees are shared equally between the parties. All other related costs incurred by the parties shall be the responsibility of whoever incurred the cost.
To submit a Level I, Level II or Mediation Appeal (see above to submit a Complaint), send complete documentation to:
Physician and Provider Appeals
P.O. Box 91102
Seattle, WA 98111-9202
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