Reminder to submit claims with complete and correct data to avoid claim denial

We recently informed you in Provider News of the change of the current provider data management system with a new and significantly improved Strategic Provider System (SPS). One of the major features of SPS requires claims be submitted with complete and correct information so claims process timely and accurately.

 

We have been experiencing a high number of claim denials due to incomplete or inaccurate information on the claims. Submitting claims with complete and correct data is critical to help ensure we are able to process your claims efficiently and accurately. All data fields on claims are used when building your claim records to process them.

 

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

 

Below are some tips to 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 national provider identification (NPI) number is reported in field NM109
• The taxpayer identification number (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 (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. 

 

Questions?

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

 

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