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Medicare Advantage Claim Edits

September 19, 2017

Beginning Sept. 16, 2017, Blue Cross and Blue Shield of Texas (BCBSTX) will implement new electronic claim submission validation edits for Blue Cross Medicare Advantage (PPO)SM and Blue Cross Medicare Advantage (HMO)SM Professional and Institutional claims (837P and 837I transactions). These claim edits will be applied to claims during the pre-adjudication process to help increase efficiencies and to comply with Medicare data reporting requirements.

Currently, these validation edits impact Blue Cross Medicare Advantage claims throughout the claim adjudication process, as well as in post-adjudication encounter data reporting, which can result in claim rejects or denials for missing data elements. Providers submitting these claims electronically on or after Sept. 16, 2017, may see new edit messages on the response files from their practice management system or clearinghouse vendor(s) before the claim is adjudicated. These responses will specify if additional data elements are necessary. If you receive claim rejections, the affected claims must be corrected and resubmitted with the needed information as specified in the rejection message.

As a reminder, Blue Cross Medicare Advantage electronic claims that are submitted through AvailityTM or Experian Health must be submitted using Payer ID 66006. If these claims are submitted via direct data entry through the Availity Web portal, providers should select the drop-down payer option of "Blue Cross Medicare Advantage." Providers who are not registered with Availity or Experian Health should contact their clearinghouses to confirm the appropriate Payer IDs to be used when submitting Blue Cross Medicare Advantage claims, as other clearinghouses may assign their own unique numbers.

If you have questions regarding an electronic claim rejection message, contact your practice management/hospital information system software vendor, billing service or clearinghouse for assistance. For additional information on electronic options, refer to the Claims and Eligibility/Electronic Commerce section of our Provider website.

Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSTX. Experian Health is an independent third party vendor and is solely responsible for its products and services. BCBSTX makes no endorsement, representations or warranties regarding any products or services offered by independent third party vendors such as Availity and Experian Health. If you have any questions about the products or services offered by such vendors, you should contact the vendor(s) directly.

Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association.

Blue Cross®, Blue Shield® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.