As Anthem Blue Cross and Blue Shield (“Anthem”) informed you in prior Provider News communications, we recently changed our operating system now called Strategic Provider System (SPS). This system change requires that submitted claims include complete and correct data so that we can process claims timely and accurately. Claims submitted incorrectly will be denied.

 

Recently, we learned that some network providers are having difficulties supplying the appropriate information on submitted claims and, as a result, are experiencing a high number of claim denials due to incomplete or inaccurate information.  

A number of professional providers are submitting claims without a billing national provider identifier (NPI) number. Submitting claims with complete and correct data is critical to help ensure we are able to process your claims efficiently and accurately. Please submit your full address including your line 2 address (suite number, unit, etc.) when applicable. All data fields are used on claims when building your claim record.

Review your billing practices carefully to ensure the provider taxpayer identification number (TIN), billing NPI, taxonomy code, and servicing/rendering provider information (if applicable) are submitted in the appropriate fields.  

Below are some tips for filing a complete and correct professional claim.

If you are filing professional claims electronically (supported by electronic data interchange or EDI):

  • Billing provider – Loop (section) 2010
    • When the billing provider is an organization healthcare provider, the organization’s NPI number is reported in field NM109
    • The TIN of the billing provider must be reported in the REF segment of this loop
  • The billing provider may be an individual only when the healthcare provider performing the services is an independent, unincorporated entity.
  • Billing provider address must hold a physical address and should not contain any of the following: "Post Office Box," "P.O. Box," "PO Box," "Lock Box," or "Lock Bin”

 

  • Rendering provider – Loop 2310
    • This loop or section of the EDI file is required when the rendering provider’s NPI is different from that carried in Loop ID-2010AA-billing provider. If not required by the EDI implementation guide, do not send.
    • The rendering provider is the person or company who rendered the care.

 

If you are filing a professional claim via mail/fax (not supported by EDI):

  • Facility information:
    • Box 32: Include the address of the servicing facility – the address where services were rendered.
    • Box 32a: servicing facility’s NPI – service location NPI
  • Billing provider
    • The billing provider’s complete name, address, and phone number must be in Box 33.
    • NPI must be reported in box 33a (the group’s organization or individual provider is an independent, unincorporated entity).
    • The TIN of the billing provider must be reported in box 25.
  • Rendering provider
    • For claims that require a rendering provider, please ensure you are reporting the rendering provider NPI in box 24J. 

 

Again, we encourage you to review your billing practices carefully to ensure proper TIN, billing NPI and rendering provider information (if applicable) are submitted in the appropriate fields. As a reminder, claims submitted incorrectly will be denied.


Questions?  We’re here to help.

 

If you have questions about this information, contact your local Anthem Blue Cross and Blue Shield Network Manager.   


869-1021-EM-CT



Featured In:
Submit claims with complete data to avoid claim denials - Connecticut