It has come to our attention that many of our clients
are still sending to Blue Shield of CA in a non HIPPA-compliant “NSF” format.
While Blue Shield was one of the last carriers in the state of California
to begin accepting the ANSI format, they have been accepting it for
over a year now, and it is definitely time to start moving into ANSI.
There are several key reasons for this:1. If all of your carriers are
ANSI, you need to only print your batch of claims once
2. S&A will be retiring support for the NSF format
3. Blue Shield will eventually cut those clients off who are still
submitting in ANSIIronically, almost all of our clients already have
the capability to submit in ANSI, as they already do so for all other
carriers, so
making the switch is not that difficult. The following steps should
help you easily set your Validator system up
Step One: Payer IDs
As you may already be aware of, the HIPAA compliant
Validator 5 uses only a single form for all of the possible payers.
This allows you
to “print” your claims for all carriers in a single batch,
and the Validator will break those claims up for you and create multiple
outbound files (one for each carrier) from the single batch you create.
In order for us to be able to do this, a “Payer ID” number
is required in your practice management system. No claims can be sent
electronically without a valid Payer ID. In Lytec, simply go to lists\insurance
companies and click on the Ids tab. If you have Lytec XE or newer,
you will want to enter 94036 into the first payer ID field, and 0524
into the second one. If you have Lytec 2001 or older, this field will
be called “Commercial ID”.
If you have more than one Blue Shield insurance company
in your practice management system, you will want to repeat this
process for each one.
Step 2: The Carrier Setup Screen in the Validator
Once you have set up your insurance company records with a payer
ID, you will want to make a few settings changes in your Validator
program. All of these changes can be found on the Carrier Setup Screen
from within the Validator program. Open the Validator and click Settings
| Carrier Setup Options from the main menu.
At the top, where it says please select a Carrier;
make sure it says “Blue Shield CA”. If it does not, choose the dropdown
arrow and select “Blue Shield CA” from the List.
While there may be slight variances in the different
releases of the Validator program, you will end up with a screen
that looks very much like the following:
The first thing you want to do is change the Test/Production
Indicator from PROD to TEST (or at least make sure it is in TEST).
Blue Shield will require you to test the new format by submitting
at least two clean ANSI test batches of claims.
Next Press the Apply Button, and click
on the Advanced Tab. From this screen, click on the rather large
button that says “Modify
ANSI Output Format”.
You will get a warning message about changing this
portion of the setup for this carrier. Click the [YES] button to
continue.
If you have Validator version 5.8.0 or above, you will see a screen
that looks exactly like the following. If you have an older Validator
5 version, you will still have all of the same fields, but we do
recommend you obtain a free update from our web site.
The field you are interested in is the “Sub-Element Separator” field
(which is highlighted in the screen shot below). If you have an older
version of the Validator 5 program, this may be set incorrectly to
a value of 58, which is the default for most carriers, but not the
correct value for Blue Shield. Blue Shield requires this value to
be 62. If you have anything other than 62 in this location, choose
the dropdown arrow and select 62 (do not just type in 62, especially
if you have an older Validator).
While you are on this screen, you should also verify
the values for the other fields, which should all match what you
see in this
screen. Pay particular attention to the “Do NOT add any Carriage
Return\Line Feeds to the Claim file” option button. Once you
have verified the settings, press the [OK] button (you do NOT need
to press Apply first, though you can).
You will get a final warning. Press [Yes].
On the Carrier Setup Screen, press [OK] to get back to the main
menu.
Step 3: Submit a Test File
Blue Shield will require you to test the new format
with them. They will want to see 2 clean batches in a row from
each of our
clients,
and each batch should contain between 20 to 30 claims. We highly
recommend generating a batch of “Tracers” for this purpose,
because test claims will not be paid, and because “tracers” represents
a good representation of the types of claims you will be submitting.
Blue Shield thankfully does not require you to show every possible
type of field like NHIC Medicare did, so you need not make up a
fake patient. Most of our clients have not had any problems passing
the
testing process the first time around, with the following exceptions:
1. Some clients, by default, have
had the “Lab Charges” box checked on their claims.
This can be found in Billing Options | Billing Information from
the Charges and Payments Screen. Checking this box will include
information Medicare wants to see, but Blue Shield does not,
so make sure it is unchecked.
2. The “ISA16” which
is also known as the sub-element separator, which we took care
of already in step 2 above. Older versions of the Validator,
or even versions that were installed a while ago and then patched,
had the wrong value for sub-element separator.
3. ICD9 codes!!! Our clients are
finding that claims which were sent in the NSF format were NOT
checked for invalid ICD9 codes, yet the new ANSI format is checked.
If you are using a code which has expired, the test batch will
not be considered “clean” and Blue Shield will not
pass you. While once you are in production with ANSI this is
a mere nuisance, it is a much larger problem in Test mode. This
is because in production, Blue Shield will only reject the offending
claim, but in Test Mode, they will call the whole batch no good.
So let us go through the steps
you will need to take to Generate a Test batch to Blue Shield:
Pull your Claims from Lytec
From the Lytec program, click on
Billing | Print Insurance Tracers . By definition, a Tracer is
a claim which has already been sent to the carrier, but which
has not received payment yet.
You will be asked to select a custom
form. If you have been submitting to Blue Shield in the older
NSF format, you likely have a form in here specifically for Blue
Shield. DO NOT USE THIS FORM. As the name implies,
this form submits your claims in the older, non-compliant NSF
format. Instead, you will want to select the newest revision
of the “Eclaims” forms that is appropriate for your
version of Lytec. This is most likely the same form you currently
use for Blue Cross of CA, NHIC Medicare, Medi-Cal, THIN, and
all of the others. In our example, we are choosing the form called “_Eclaims
4010A1 for Lytec 2004 Rev8.lns”
Once you select the form and click
the open button (or alternatively double-click on the form) you
will see the “Print Insurance Tracers” screen. Click
on the Include Tab (older versions of Lytec call this the “Ranges” tab).
The screen below allows you to
select a set of Ranges. For the purpose of this test, you want
to pull ONLY Blue Shield claims. This is most commonly accomplished
by choosing a range of Insurance Companies from Blue Shield to
Blue Shield. If you have more than one Blue Shield insurance
company, and the codes are not next to each other alphabetically,
you will want to use the Insurance Company Categories feature
of Lytec XE and up, or the Patient Code or Patient Type feature
of Lytec 2001 or below. We will not go into the use of those
features in this tutorial.
If I were printing a batch of new Blue Shield claims,
that is the only filter, or “Range” I would need to use. Since
we are printing tracers, and we want our test batch to have ONLY
20 to 30 claims, we will want to also limit the claims we pull
by Billing Created date. You use the appropriate date ranges to
assure you get between 20 and 30 claims in the batch. You should
use recent date ranges, as the further you go back; the more likely
the claim has been paid, and thus would not show up in this batch
anyway. Once you have put your “Ranges” in, press the
[Print] button.
This will generate your batch of
test claims. Pay attention to how many “Pages” are
being generated. If you go over 30, you may want to cancel the
batch and try again with stricter date ranges. If you get a “Find
EDI Receiver” box, just click [Cancel].
Process your Claims in the Validator
This is done the same way. Bring
up the Validator program and click Process|New File.
This will automatically load the claims and start checking them for
errors.
If you encounter any errors for which you do not know the answer
to, the safest option is to choose [Exclude] as opposed to [Ignore].
Transmit your Claims to Blue Shield
Once your files have been checked for errors, you
will see the following screen. Click on the “Blue Shield CA” batch
you just created (if there is more than one, choose the one with
the highest
batch number).
It should now say “SELECTED” in the Claim
Status Column. Click the [Transmit Selected] button
On the Terminal Screen that comes up, press the button for Sending
Claims AND receiving mail.
You have now submitted your first test batch to Blue
Shield of CA. You should hear from Kelli Gonczeruk, who is your
testing analyst
for Blue Shield of CA. Her telephone number is 530-351-6058 and her
e-mail address is Kelli.Gonczeruk@blueshieldca.com. If there is anything
wrong with your test file which is not a simple fix (like an invalid
diagnosis code), Kelli usually contacts us in addition to letting
you know what was wrong. You can expect that it will take 48 hours
to get a response from Blue Shield as to the status of your test
file. If you would like to submit claims in the old format while
awaiting approval for the new format, you may do so, but remember
to switch your TEST\PROD indicator back to “PROD” when
submitting in NSF.
The sooner you switch to ANSI, the less likely you
will be put into a situation where you cannot submit claims. Stephens & Associates,
like always, is here to assist you in whatever way we can!
