BMC HealthNet Plan takes electronic claims in the HIPAA-compliant X12N 837 version 4010 formats. Currently over 75% of claims are submitted to us electronically. We have active relationships with three of the largest clearinghouses in America and can also take electronic claims directly.

1. Who can submit electronic claims to BMC HealthNet Plan?
2. What clearinghouses does the Plan work with?
3. What is a billing agency?
4. What is an 837 file?
5. How can providers send electronic claims to the Plan?
6. How can providers submit electronic claims directly to the Plan?
7. Can providers tell if the Plan accepted the claims they submitted?
8. Why are a provider’s claims being rejected?
9. Can providers submit corrected claims electronically?
10. How can providers get Electronic Remittance Advices (835s)?
11. How can providers get more information about EDI/electronic claims?
12. Do providers have to send claims electronically to BMCHP?

Providers—whether participating or non-participating—who send claims to BMC HealthNet Plan can do so electronically if they have a BMC HealthNet Plan Provider ID and meet any one of the following criteria:

• They can produce claims in HIPAA-compliant 837 format.
• They use a billing agency that can produce HIPAA-compliant 837 files.
• They use one of the clearinghouses listed below (or a clearinghouse or billing agency that uses one of the clearinghouses listed below).

If a provider already sends electronic claims to another insurance plan, chances are that provider can send claims to BMC HealthNet Plan, too. However, if the provider is using a special piece of software from MassHealth or MBHP that sends claims over a modem only to MassHealth or MBHP, that will not be sufficient.

NOTE:  The provider must have a BMC HealthNet Plan Provider ID number(s). Claims submitted without a Plan Provider ID will be rejected. If a non-participating provider or a new doctor at a participating provider practice does not have a Plan Provider ID, that provider should contact his or her assigned Provider Account Representative or call our provider line at 1-888-566-0008 to have a number assigned. (There is a form that can be sent to the provider, completed, and returned to expedite the process.) The requirement of a BMC HealthNet Plan Provider ID on claims will exist until May 23, 2007, at which time the Plan will require an NPI (National Provider Identifier) instead.

A clearinghouse is a company that takes claims information from any doctor, hospital, etc., and sends claims to “payers” (e.g., insurance companies like Blue Cross Blue Shield) on paper or as electronic files. Large clearinghouses have many subsidiaries, usually billing or claims companies that they have bought. For instance, Emdeon (formerly known as WebMD) bought Envoy, which used to be the biggest clearinghouse. Emdeon also bought Medical Manager, a company that produces software many doctors use to send electronic claims.

We now have active relationships with three of the largest clearinghouses in America: Emdeon (also known as WebMD, NEIC, Envoy, HealthWire, Medical Manager, and by other names), The SSI Group, and MedAvant (formerly known as ProxyMed, MedUnite and NDC).

CLEARINGHOUSE	BMC HEALTHNET PLAN’S PAYER ID
emdeon	13337
MedAvant	13337
The SSI Group	0515

Basically, billing agencies are the ”middle men” between providers (e.g., doctors/facilities) and clearinghouses and/or payers. Billing agencies create claims for providers using the information the provider sends to them. Billing agencies often give providers software to use to send the claims information. Many billing agencies then send paper claims or electronic claims to clearinghouses.

An 837 is a certain kind of electronic claims file that HIPAA requires for use by providers who submit claims electronically . There are some older forms of the 837 file, but HIPAA requires that health plans and EDI submitters use the latest version, called “X12N 837 version 4010.” There are very specific rules about what kind of information can go in an 837 and exactly where that information should be put. Doctors who bill using the paper HCFA-1500 form would use Professional format; hospitals and facilities that use the paper UB-92 form would use an 837I (the I is for Institutional). Most doctors can’t produce 837 files directly, so if they want to send electronic claims, they must use a clearinghouse or billing agency that can produce the 837 files for them. The current HIPAA-compliant 837 form is also sometimes known as the “Addenda version” and has these numerical designations:

837P: 004010X098A1 837I: 004010X096A1

There are several alternatives for submitting claims to the Plan:

1. Providers who send claims through NEHEN can send claims to BMC HealthNet Plan. NEHEN subscribers should contact their NEHEN Technical Support representative to request setup.
2. Providers can send claims directly to BMC HealthNet Plan. If a provider produces claims in an 837 format or uses a billing agency that can produce claims in an 837 format, the Plan can take those files directly (see Question 6).
3. Providers can send claims directly to BMC HealthNet Plan. If a provider produces claims in an 837 format or uses a billing agency that can produce claims in an 837 format, the Plan can take those files directly (see Question 6).

We can take electronic claims directly from a provider instead of a clearinghouse. To do so, the provider or its billing agency must be able to produce an 837 file, have an Internet connection (to transmit the claims files), and have either Secure FTP software (e.g., WS_FTP Pro, Cute FTP) or PGP encryption software to satisfy HIPAA Privacy/Security regulations. Providers or billing agencies interested in submitting claims directly to BMC HealthNet Plan should contact us at 617-748-6175; our EDI Claims Companion Guide (PDF) is also available.

If providers use a clearinghouse to send us electronic claims, they should receive Initial Claims Status reports from that clearinghouse telling them what happened to the claims they sent; if they do not get those reports, providers should ask their clearinghouse contacts for that information. Some clearinghouses only tell providers what claims did NOT make it into BMC HealthNet Plan’s system; others show all the submitted claims and if they were accepted or rejected, and the reason a rejected claim did not make it into the Plan’s system. The only time an initial electronic claim will not make it into the Plan’s system is if the provider has used an unrecognized BMC HealthNet Plan Provider ID or an unrecognized Member ID. Providers can also check on the status of claims they’ve submitted by logging into the Plan’s Web site (if they’re participating providers) or calling our provider line at 1-888-566-0008.

All providers sending electronic claims MUST submit a valid 12-digit BMC HealthNet Plan Provider ID AND a valid Member ID or the claims will reject from our system. (Note that as of May 23, 2007, HIPAA requires that BMC HealthNet Plan use a National Provider Identifier instead of a BMC HealthNet Plan Provider ID.)

BMC HealthNet Plan rejects initial claims submissions for only two reasons: unrecognized Member IDs or unrecognized BMC HealthNet Plan Provider IDs. For electronic claims, those IDs must be in certain locations in the 837s with certain qualifiers. We often find that a provider’s software shows the correct IDs on the screen, but the 837 that we receive from the clearinghouse has the IDs in the wrong location or with the wrong qualifier.

For corrected claims (see Question 9 below), there are additional criteria that must be satisfied that will cause an electronic claim to reject.

Providers can submit corrected claims electronically using the 837 format, but there are very specific rules for doing so required by the 837 format and outlined in our EDI Claims Companion Guide (PDF) on pages 15 and 16. Basically, corrected claims are submitted electronically as “replacement claims,” which have frequency codes of 7.

UB-92 submitters are familiar with frequency codes from Form Locator 4, but frequency codes are new to HCFA submitters. A replacement claim asks the insurance company to take a specified claim received earlier and replace it with newly submitted information. Corrected claims must meet additional criteria to be accepted: they must include an original BMC HealthNet Plan claim number in a finalized status, and the Member ID and Plan Provider ID must be the same on the corrected claim and the original claim.

Here’s a simplified example:

• A provider sends a claim to BMC HealthNet Plan in January with three line items and a total charge of $250.
• BMC HealthNet Plan gives the claim an ID of E00306842700 and pays the provider $250.
• In February the provider realizes the claim should have had five line items and a total charge of $400.
• The provider submits an electronic claim with a frequency code of 7, referencing the original claim ID of E00306842700, and showing all five line items (not just the two new line items).
• BMC HealthNet Plan processes the replacement claim, assigns a new ID of E00306842701,   and pays the claim.

Providers who submit electronic claims directly to BMC HealthNet Plan can get electronic remittance advices, also known as 835s, which is the HIPAA name for the electronic file. (Some providers who use The SSI Group clearinghouse can also get 835s.) Providers submitting claims to the Plan through NEHEN will also be able to get an 835 for those claims through NEHEN. Currently our 835s do not include any paper claims, so paper remittance advices are still sent to any providers receiving payments. Providers who submit electronic claims directly to us and who want to get 835s should contact us at 617-748-6175.

Providers can download a copy of our EDI Claims Companion Guide (PDF), which outlines our testing procedures and communications setup and gives Plan-specific information about creating 837 format files. The guide has general billing/EDI claims information and some very specific technical sections.

No. Providers can still send paper claims. Also, if a provider is billing for a service that requires an invoice or attachment (e.g., Durable Medical Equipment, COB claims), those claims should not be sent electronically. Please note, though, that paper claims will also be rejected without a valid BMC HealthNet Plan Provider ID.