new cessna ddiabbetiic ssuppply coverage · 2012. 1. 5. · blood glucose test strips 50 strips 050...

Sent to: CAP HME

September 11, 2001 S-15-01

Questions: Contact your Professional Relations Representative, or the Professional Relations Hotline in Topeka at 785-291-7878 or 1-800-432-0216 ext. 7878.

OUR WEB ADDRESS: http://www.bcbsks.com

The Blue Shield Report is published by your

Professional Relations Department.

Communication Coordinator

Larry Callahan

Inside This Issue… Cessna Diabetic Supply Coverage Pg. 1 HME Provider Instructions For Completing the HCFA 1500 Form Pg. 2

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s of January 2001, Cessna benefits have been administered through Blue Cross and Blue Shield of Kansas

(BCBSKS). Some adjustments were made with the change of administration, and there has been some confusion as to who to bill for diabetic supplies. Previously, home medical equipment, such as diabetic supplies, were billed under the

prescription drug benefit for Cessna members. This is not the case for administration under BCBSKS and Cessna diabetic supplies should be billed directly to BCBSKS. Billing should be submitted on the HCFA 1500 form. BCBSKS will reimburse home medical equipment, including diabetic supplies, at 100 percent of the maximum allowable payment (MAP) and Cessna members should not be billed up front by Competitive Allowance Program (CAP) contracting providers for their supplies. If you have any questions regarding Cessna benefits, please contact Vikki Lindemuth in Topeka at 785-291-7724 or 1-800-432-0216, extension 7724.

Blue Shield Report S-15-01 September 11, 2001

Sent to: CAP HME

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If you would like information about submitting the HCFA 1500 form electronically, please call the Administrative Services of Kansas, Inc. in Topeka at 785-291-7135 or 1-800-472-6481. Following are the specific completion guidelines for submitting the HCFA 1500 claim form by a Home Medical Equipment supplier to BCBSKS. If you have any questions about completing the HCFA 1500 form as an HME provider, please contact Vikki Lindemuth in Topeka at 785-291-7724 or 1-800-432-0216, extension 7724.

Box 1 - Type of Claim • Always Check “other” when submitting any BCBSKS or Premier Blue Claim. • Only one box should be checked, and it should be the primary insurer. • It’s helpful if you separate your claims by: Medicaid, Medicare, BCBSKS, and Premier Blue.

Box 1A - Insured's I.D. Number • Include all alpha and numeric

characters. • The BCBSKS identification

numbers are usually XSA, followed by 9 numeric characters. • Premier Blue identification numbers begin with XSP, followed by 9 numeric characters. • FEP identification numbers begin with an “R,” followed by 8 numeric characters • Do not include the individual patient identifier found on FEP ID cards.

Box 2 - Patient's Name • Enter the information exactly as displayed on the identification card.


Sent to: CAP HME

Box 3 - Patient's Birth Date and Sex

• This field is eight digits, using four digits for the year.

Box 4 – Insured’s Name • This field is for the primary insurance coverage.

Secondary insurance coverage information is entered in Box 9.

• The member is the holder of the policy/health insurance contract. The patient receiving services may, or may not be the member. If the member is not the patient, you must specify who the member is in box 4.

Box 5 – Patient’s Address Box 6 – Patient’s Relationship to

Member

Box 7 – Insured’s Address

• If the Insured’s address is the

same as the patient’s address, you can simply put “same” in the first box.


Sent to: CAP HME

Box 8 – Patient’s Status • This information is helpful if available.

Box 9a, 9b, 9c and 9d • 9b may be left blank. • 9c may be left blank.

Box 10a, 10b, and 10c

• If the patient has not experienced some type of

injury, you should mark all boxes “no.”

• If the patient has experienced some type of injury, you should mark the appropriate box “yes.”

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Sent to: CAP HME

Box 10d – Reserved for Local Use • This box may be left blank.

Box 11a, 11b, 11c, and 11d • 11d is helpful for benefit

coordination. If this box is marked “yes,” then you must complete boxes 9, 9a, 9b, 9c, and 9d as outlined previously.

Box 12 – Patient’s or Authorized Person’s Signature

• This box may be left blank because BCBSKS is granted authorization when you sign your contract.

Box 13 – Insured’s or Authorized person’s signature • This box should be left blank

since you are a CAP contracting provider.


Sent to: CAP HME

Box 14 – Date of Current: Illness, Injury, or Pregnancy

• Complete only if an injury has occurred.

Box 15 – If Patient Has Had Same or Similar Illness, Give First Date • This box may be left blank. Box 16 - Dates Patient Unable to Work in Current Occupation

• This box

may be left blank.

Box 17 - Name of Referring Physician or Other Source • Specialty providers and referral specialists should complete this field when they have:

1. A referral from a PCP 2. A Certificate of Medical Necessity (CMN) from an MD, DO, or DC for a piece of medical

equipment. NOTE: Neither a referral nor a CMN is required for diabetic supplies.

Box 17a - ID Number of Referring Physician • If you have a name in Box 17, then you should

also have a UPIN number in Box 17a.


Sent to: CAP HME

Box 18 - Hospitalization Dates • This Box may be

left blank.

Box 19 - Reserved For Local Use • This box should always be completed when additional information is available. Following are

some examples of such information, but it is not an all-inclusive list. ! Accident information (such as where and how the accident happened). ! Origination and destination of ambulance transports. ! Description of unclassified, unspecified, unlisted, or not otherwise classified procedures.

Box 20 B - Outside Lab Charges

• This Box may be

left blank.

Box 21 - Diagnosis or Nature of Illness or Injury

• All claims must have at least one diagnosis. • Each claim may have up to four diagnoses. • Code to the greatest specificity. Use your five-digit codes according to ICD-9 coding guidelines, if

required.


Sent to: CAP HME

Box 22 - Medicaid Resubmission • This Box may be left

blank.

Box 23 - Prior Authorization Number • If you have received a referral from a PCP, the referral number should be entered in this box.

Box 24 A - Dates of Service When NOT billing a date range: When billing a date range:

Box 24 B - Place of Service • You should always complete this box using place of service 12, which signifies

Patient's Home.


Sent to: CAP HME

Box 24 C - Type of Service • You must use either the appropriate Type of Service code, or complete Box 24D with the

appropriate modifier.

9 Other Medical Service (such as diabetic supplies) W DME/HME Rental

A DME/HME Purchase (Used) Use is Mandatory X DME/HME Purchase (New)

Use is Mandatory

Box 24 D - Procedures, Services, or Supplies • Refer to the HCPCS listing for appropriate procedure

codes. • Modifiers are sometimes appropriate in place of the

type of service code. They are used to help describe the service rendered or to request special attention be given to the service when processing. When billing two-digit modifiers: ! Modifiers immediately follow the procedure code, with no space between. ! Modifier NU means New Home Medical Equipment, such as diabetic supplies. ! Modifier RR means Rental of Home Medical Equipment. ! Modifier UE means Used Home Medical Equipment Purchase.

Box 24 E - Diagnosis Code • The numbers placed in this box should be 1, 2, 3, 4, or a combination thereof, as the

line of service relates to the diagnosis codes in Box 21. • Never enter “1-4”, or "all". • You may enter "1,2,3,4" on one line, when applicable.

Box 24 F - Charges • This box should reflect your total charge for that

particular service.


Sent to: CAP HME

Box 24 G - Days or Units Service Performed Units Units Field Ambulance loaded miles 100 100 Eye glass lenses of the same power 2 002 Hearing aids 2 002 Ostomy bags Box of 24 024 Modality 30 minutes and code is per 15 minute

increments 002

Occupational Therapy Subsequent 30 minutes and code is per 15 minute increments

002

Repair prosthetic 2 hours 002 Blood glucose test strips 50 strips 050 Lancets 100 lancets 100

Box 24 H, 24 I, 24 J, and 24 K These boxes may be left blank.

• NOTE: Box 24 K does not apply to HME providers.

Box 25 - Federal Tax I.D. Number • This information is helpful

when available.

Box 26 - Patient's Account No.

• If your office uses patient account numbers, you may enter this number in box 26. This number will appear on the remittance advice for the claim.


Sent to: CAP HME

Box 27 - Accept Assignment? • This box should be left blank since you are a CAP provider.

Box 28 - Total Charge This box must be completed with the grand total for all of the services.

Box 29 - Amount Paid • This box may be left blank. • If the patient has paid an amount for the service(s) listed on the claim,

you may show that amount. • If you are a CAP provider, this amount should only be for non-

covered service(s), unmet deductible amounts, unmet co-insurance, co-payments, and indemnified payment balances.

Box 30 - Balance Due • This box may be left blank.

Box 31 - Signature of Physician or Supplier

• Enter the date the claim was submitted

to BCBSKS.


Sent to: CAP HME

Box 32 - Name and Address of Facility Where Services Were Rendered • As an HME provider, this box

should be left blank.

Box 33 - Physician's, Supplier's Billing Name, Address, Zip Code and Phone Number

• You should always give your complete name and address as it appears on BCBSKS records. • Your HME provider number must be in the PIN # field. • Box 33 should look like this if the provider is an HME provider, and Box 24K should be blank:

new cessna ddiabbetiic ssuppply coverage · 2012. 1. 5. · blood glucose test strips 50 strips 050...

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