Claim Submission and Payments

  • Submitting claims

  • 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:

    • Box 25– Enter the applicable tax ID number.
    • Box 31– Enter the physician or provider’s name that performed the service.
    • Box 33– Enter the “contract name” of physician or provider who performed the service.

    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 from the date of submission. 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:

    • Use only red CMS-1500 forms (no photocopied forms).
    • Type forms in black ink (handwritten forms cannot be read by OCR equipment).
    • Don’t fold, staple, or tape your claim.
    • Be sure information lines up correctly within the respective fields (data that overlaps another field/box cannot be read accurately).
    • Don’t write or stamp extra information on the form.
    • Avoid white correction fluid.
    • Avoid highlighting information.

    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.

    Submitting a Corrected Claim on Paper

    If submitting a corrected claim on paper, remember to:

    • Submit as a replacement claim, clearly marking the claim as a corrected claim; failure to indicate that a claim is a corrected claim may result in a denial as a duplicate claim.
    • Bill all original lines-not including all of the original lines will cause the claim to be rejected.
    • Attach a completed “Corrected Claim - Standard Cover Sheet.”
    • In box 22 on the CMS-1500 Claim form, enter the appropriate bill frequency code, left justified in the left hand side of the field.  Use the following codes:
      • 7– Replacement of prior claim
      • 8– Void/cancel of prior claim
    • In the “Original.Ref.Co” segment of box 22 enter the original claim number

    Obtain Corrected Claim - Standard Cover Sheets at in the administration simplification claims processing section, or under Forms on our provider website.

    Submitting a Corrected Claim via an 837 Transaction

    If submitting a corrected claim electronically, remember to:

    • User the HIPAA 837 standard claims transaction including the following information:
      • Frequency code of “7” in look 2300, CLM05-3 segment to indicate a corrected/replacement of a previously processed claim.  Use “8” to void a claim billed in error
      • The initial claim number (in loop 2300, REF01 must contain “F8” and REF02 must contain the claim number)
      • A free form note with an explanation for the corrected/replacement claim, in loop 2300 claim note as:
        • For professional and dental claims:  segment NTE01 must contain “ADD” and segment NET02 must contain the note, for example: NTE*ADD*CORRECTED PROCEDURE CODE (or whatever data element was corrected/changed on the claim)
        • For facility/institutional claims:  segment NTE01 must contain “UPI” and segment NTE02 must contain the note, for example: NTE*UPI*CORRECTED LAB CHARGES (or whatever data element was corrected/changed on the claim)

    For additional instructions on electronic corrected, replacement or voided claims, visit the online section “Electronic Transactions and Claim Payer ID”, for additional information.

    You can obtain the status of a claim:

    1. Online: The best method to check the status of a claim is to visit our website. Information is available 24 hours a day, seven days a week.
    2. Customer Service: If you don't have Internet access, contact Customer Service by calling 877-342-5258, option 2, or by calling the phone number on back of member's ID card.
    3. Interactive Voice Response (IVR): Available 24 hours a day, seven days a week. IVR provides claims information.

    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.

    All services rendered by the same provider for the same patient for the same date of service must be submitted on one claim form.   Claim edits in place will identify those services previously billed and bundle ALL services on to a single claim and apply additional edits if applicable.

    When a Medicare patient received services that Medicare specifically requires to be submitted on separate claim forms, this “one claim requirement” will not apply.

    Be sure to submit a paper CMS-1500 claim form or electronic 837P claim form that is complete and accurately filled out. Here are common reasons why claims suspend or reject:

    • Information doesn't match: Physician/provider information doesn't exactly match what is in our payment system.
    • Rebilling: Records are missing when rebilling with a different diagnosis or other change. The claim rejects if records are not attached that support the change.
    • Anesthesia: The hours/minutes for anesthesia claims are not included. Anesthesia time is billed in units to represent minutes and additional base units for the code.
    • Home IV drugs: NDC number and quantity is missing.
    • Advanced registered nurse practitioner: Supervising physician's name is missing for non-credentialed and/or not contracted ARNP.
    • Physician Assistant: Supervising physician's name is missing for PA (Note: A PA does not need to bill with a supervising physician if he/she is a Surgical Assistant and has completed the paperwork to be set up independently in our payment systems).
    • Codes: The person submitting the claim used invalid CPT/HCPCS, modifiers, or diagnosis codes.
    • Date of current illness: The onset date was missing from box 14 in the CMS-1500 claim form.
    • Incorrect member number: Provider billed with an incorrect member number (e.g. social security number, incomplete member number, transposed digits in member number).

    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.

  • CMS 1500 form completion

    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:

    • Anesthesia
    • Office visits
    • Day surgery/professional
    • Emergency physician services
    • Mental health
    • Obstetrics
    • Occupational therapy
    • Pathology/interpretation
    • Physical therapy
    • Radiology/interpretation
    • Speech therapy

    This includes claims for outpatient services and services performed by a hospital-based physician or other qualified healthcare provider.

    Patient account numbers assigned by your office

    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:

    • Premera Blue Cross Blue Shield of Alaska Participating (Traditional/Indemnity) and Preferred/BestCare (PPO)
    • Premera Dental
    • FEP
    • National Account Service Company (NASCO)
    • BlueCard (out of area)
    • Dimensions (HeritagePlus, HeritageSelect, or Global)


    Submit claims electronically for:

    • Faster claims payment turnaround
    • Less time spent on claims preparation
    • Validation to ensure that they are HIPAA-compliant
    • Detailed claim acceptance and rejection reporting

    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).

    Getting started

    To help you move from paper to electronic claims, follow these steps:

    1. If you are interested in purchasing a new computer system, ask us for a list of vendors that submit claims to us in the HIPAA standard ANSI 837 format.
    2. If you already have a computer system, notify your software vendor of your desire to convert to electronic claims. You will need special software to send insurance claims electronically.
    3. Call EDI at 800-435-2715 for information. They will send you the following documents:
      • EDI Enrollment Information
      • Secure Transport (ST) User Guide
      • Testing process information
    4. Your software vendor can help you set up your computer to accommodate Premera's billing requirements.
    5. Plan to submit test claims. Continue to submit paper claims until you are told to stop. We review test claims for accuracy, but we don't process them for payment.
    6. An EDI representative will review the test claims with you or your vendor. We'll notify you in writing or by telephone when you have successfully completed the test phase. When this notification has occurred, change the indicator on your claims from (T)est to (P)roduction and begin submitting live electronic claims. At that time, please discontinue submitting paper claims.

    Submitting secondary claims electronically

    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:

    1. A member is primary on the plan in which he/she is the subscriber versus the plan in which he/she is a dependent. When a member is the subscriber on more than one plan, when both plans have a COB provision, the plan with the earliest start date pays first (primary).
    2. When a dependent is double-covered under married parents' health plans, the primary plan is the coverage of the parent with his/her birthday earlier in the year, regardless of their actual age. This standard is called the "“Birthday Rule."
    3. When dependent children are double-covered by divorced parents, coverage depends on any court decrees. Generally, if the court decrees financial responsibility for the child's healthcare to one parent, that parent's health plan always pays first. If there are no court decrees, the plan of the parent with custody is primary.

    Some group contracts are not subject to state regulations may have unique COB rules that could change the order of liability.

    Billing information

    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.

    How payments are made

    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.

    Injury Accident Claims

    The member's benefit program contains special provisions for benefits when an injury or condition is:

    • Caused by another party (e.g., slip and fall, medical malpractice, etc.)
    • Covered under the provisions of motor vehicle medical policy, personal injury protection (PIP), medical payments (Medpay)
    • Uninsured (UIM) and/or underinsured (UM) motorist or other similar coverage (e.g., homeowners, commercial medical premises)
    • Covered by Worker's Compensation.

    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 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:

    • Fax it to: 425-918-5878
    • Mail it to: Subrogation Department
      MS 227
      P.O. Box 327
      Seattle, WA 98111-327

    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

    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.

  • Reimbursement

  • 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:

    • Physician work: The work value reflects the cost of the physician's time and skill for each service.
    • Practice expense: The physician's direct (non-physician labor, medical equipment, medical supplies) and indirect (general office supplies, rent, utilities, office overhead) costs related to each service.
    • Malpractice insurance: The malpractice insurance component

    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.

    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:

    • Checks for eligibility of the member listed on the claim
    • Checks for completeness of the claim
    • Confirms the accuracy of the information
    • Compares the services provided on the claim to the benefits in the subscriber’s contract
    • Applies industry standard claim edits and applicable payment policy criteria
    • Concludes the payment amount

    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 editors 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. These claim editors evaluate billing information and coding accuracy on submitted claims and assists in achieving consistent, accurate, and timely processing of physician and provider payments.

  • Payment policies

    Our Provider 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 policies and edits are applied. Payment policy:

    • Applies to professional and facility claims 
    • Does not determine the reimbursement dollar amount for any particular service (reimbursement is specific to the provider applicable fee schedule).
    • Is distinct from our medical policy, which sets forth whether a procedure is medically necessary/appropriate, investigational or experimental and whether treatment is appropriate for the condition treated.

    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 the 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:

    • Mail the overpayment amount to our finance department (address on check) along with a completed Refund Request form, or
    • Mail a completed Overpayment Notification form (found in our online library under Forms) and mark the box requesting a voucher deduction to recover the overpayment on future claim payments.

    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.

    Washington contracted providers: 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:

    • Pay or deny 95 percent of a provider's monthly clean claims within 30 days of receipt; and
    • Pay or deny 95 percent of a provider's monthly volume of all claims within 60 days of receipt.

    If the above standards are met, the regulation does not require interest for those individual claims paid outside of the 95 percent threshold.

    Alaska contracted and non-contracted providers: We process your claim as soon as we receive them. We also apply the following Prompt Pay standards set by the State of Alaska to our claims adjudication process in order to:

    • Pay clean claims within 30 days of receipt; and
    • Pay unclean claims within 15 days after receipt of information

    Oregon contracted and non-contracted providers: We process your claim as soon as we receive them. We also apply the following Prompt Pay standards set by the Oregon Insurance Division to our claims adjudication process in order to:

    • Pay clean claims within 30 days of receipt; and
    • Pay unclean claims within 30 days after receipt of information

    Clean claim definition

    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:

    • They are suspended due to the group or individual's non-payment of premium or dues.
    • They have Coordination of Benefits when we are the secondary carrier on the claim.
    • They require completion and mailing of an Incident Questionnaire for possible accident investigation or a Workers Compensation injury (claims in subrogation).
    • They include a request of medical records for review.

    Applying interest

    AlaskaProviders (Non-contracted and contracted): 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. Unclean claims will begin to accrue interest on the 16th day from receipt of the information.

    Washington Contracted Providers: If we fail to satisfy either of the above standards, we’ll pay interest on each claim that took longer than 60 days to process at a 12 percent annual rate (unclean days are not applied toward the 60 day calculation).

    Oregon Providers (non-contracted and contracted): If we fail to satisfy any of the above standards, commencing on the 31st day, we’ll pay interest at a 12 percent annual rate on the unpaid or un-denied clean claim. Unclean claims will begin to accrue interest on the 31st day from receipt of the information.

    Please note: Exclusions to paying interest may apply based on line of business.

    Interest vouchers

    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.

    Interest threshold

    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.

    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

    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

  • Explanation 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.

    sample EOP

    EOP form descriptions

      Field Name Description
    A Patient Name Patient/member name
      Subscriber Number and Pt Suffix Subscriber's number and patient suffix number (including plan prefix) assigned by plan as shown on the member's identification card
      Patient Account Number Number assigned by the clinic for patient. (If no account number is assigned, the words “No Patient Account #” are noted.)
      Subscriber Name Name of the subscriber
      Claim Number Number assigned to the claim when received by plan
      Provider of Service Provider who rendered the service. Professional example: GENERAL CLINIC is the provider of service.
    B Service Dates The dates-of-service (to and from - also referred to as beginning and ending dates) at a line item level
    C Code/Modifier The code/modifier shown in box 24D of the CMS-1500
    D Units Billed/Allowed and Paid to Units shown in box 24G of the CMS-1500 form. “Paid to” refers to the payee code (where the check was sent/issued) and is listed only in the claim total or subtotal line (e.g., G = Provider Group).
    E APG/DRG/Room Type Applicable to facility claims only - reflects the APG code, DRG code, or room type that may relate to the reimbursement amounts. (Field not populated for CMS-1500 claims.)
    F Billed Charges Charges billed by physician/provider at a line item level
    G Allowed Amount Amount allowed for service at a line item level
    H Provider Adjustment “Provider write-off” amount
    I Other Insurance Amount paid by other carrier(s)
    J Patient Liability Total patient liability: Amount owed by patient. Patient liability is deductible and copay/coinsurance and ineligible amounts rolled up.
    • FEE ADJUST (A) = Member responsibility per subscriber contract
    • COB SAV APP (B) = Amount applied from member's COB saving account
    • COINSURANCE (C) = A predetermined amount designated by the subscriber's plan. Applies after the patient meets his/her deductible.
    • DEDUCTIBLE (D) = A predetermined amount designated by the subscriber's plan, must be satisfied by member before benefits apply
    • INELIGIBLE (I) = Services that the member does not have a benefit predetermined by the plan
    • COPAY (P) = Amount member is responsible to pay at time of service (e.g., $20 office visit copay)
    K Payable Amount Amount payable by plan
    L Reason remark Adjudication explanation code(s) at a line item level and claim level (if applicable)
    M Claim Total Printed at the end of each claim, the line items are summed and an asterisk indicates the claim total line
    N Paid To Indicates the claim payment recipient
    O Less “Paid to” Codes Listed as “S” or “C” The sum of the claim total “Payable Amounts” which have a “PD TO” code of S or C
    P Total Recovered This Payment Cycle The sum of any amount withheld and applied to a prior refund or recovery
    Q Total Payable Amount Indicates the amount of the check

    EOP codes and messages

    The most commonly occurring codes and messages are listed below. A comprehensive list is posted in the Library under Reference Info.

    EOP Code Printed Message
    202 A required waiting period must pass before we can provide benefits for this service.
    318 We forwarded this claim to the member's home plan for processing.
    401 Our medical staff reviewed this claim and determined that this admission doesn't meet the criteria for medical necessity.
    402 Our medical staff reviewed this claim and determined that this continued stay doesn't meet the criteria for medical necessity.
    403 Our medical staff reviewed this claim and determined that this service isn't covered by the plan.
    406 Payment of this claim depended on our review of information from the provider. We haven't received the information.
    453 We can't process this claim until the incident questionnaire we sent the member is fully completed, signed and returned.
    466 This is a claim adjustment of a previously processed claim.
    473 Need information from the member's other insurance carrier to process claim. Send us other carrier's explanation of benefits.
    474 The provider needs to submit itemized charges to us.
    480 We can't process this claim until the questionnaire we recently sent the member is completed and returned to us.
    487 To pay this claim, we needed to review information from the provider. We haven't received the information.
    497 This is a duplicate of a previously denied claim.
    498 This claim was paid previously to the provider or applied to the member's deductible.
    500 This member wasn't eligible for services on the date of service.
    550 This member wasn't eligible for services on the date of service.
    551 The maximum limit has been met for this benefit.
    575 This procedure is considered cosmetic. The plan doesn't cover cosmetic services.
    578 The plan doesn't cover this service.
    581 This service is considered a standard exclusion.
    741 The charges for this service have been combined into the primary procedure based on the provider's contract.
    763 These charges are included in the main anesthesia service.
    800 We can't process this claim because we haven't received the necessary information we requested from your provider.
    801 We can't process this claim because we haven't received your response to our request for information.
    840 This claim is a duplicate of a previously submitted claim for this member.
    844 Provider: send us the member's medical records for this claim. We can process the claim after we receive that information.
    845 Provider: please send us your office notes for this claim. We can process the claim after we receive that information.
    846 Provider: please send us your operative notes for this claim. We can process the claim after we receive that information.
    847 Provider: please send us the member's lab results for this claim. We can process the claim after we receive that information.
    848 Provider: please send us the radiology reports for this claim. We can process the claim after we receive that information.
    876 Provider: send us the NDC #, quantity and date span for this claim. We can process the claim after we receive that information.
    877 Provider: send us medical records relating to prescription drug charges. We'll process the claim after we receive that information.
  • Statement of overpayment recoveries

    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:

    • An amount is deducted from your check.
    • An overpayment was recorded during the payment cycle.
    • There is a balance due to us at the end of the payment cycle.
    • Money was posted to your account during the payment cycle.
    • There is other activity on your account during the payment cycle.

    Provider appeals

    Physicians and providers have the right to appeal certain actions of ours. Our provider complaints and appeals process ensure 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.


    You can submit a complaint about one of our actions (verbally or in writing) to one of our employees. 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 can make a complaint verbally to Customer Service or in writing to Customer Service Correspondence. You can reach Customer Service by calling 877-342-5258, option 2. The plan mailing addresses are available on our website under Contact Us.

    Level I appeal

    A Level I Appeal is used to dispute one of our actions.

    The Level I Appeal must be submitted within 365-days following the action that prompted the dispute. Only appeals received within this 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:

    Billing Examples Non-Billing Examples
    Multiple Modifier Reimbursement Service not a benefit of subscriber's contract
    Bundling or Inclusive Procedures Investigational or experimental procedure

    A Level I Appeal must be submitted with complete supporting documentation that includes all of the following:

    1. A detailed description of the disputed issue
    2. Your position on the disputed issue
    3. All evidence offered by you in support of your position including medical records
    4. A description of the resolution you are requesting

    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. Only a member can request a Level I or 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 appeal

    Level II appeals must be submitted in writing within 30 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.

    Submitting an appeal

    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