Provider Central

Claims submitted through ConnectCenter

ConnectCenter provides you with many tools for tracking your claims. You can:

• Review your Worklists and the Claim Health Vitals on your home page for a bird’s eye view of claims you submitted in the last 30 days. Use the filters to reduce or increase the number of claims in this area. Learn more in our ConnectCenter Quick Start Guide.
• Use the Claim Search and Claim Status features to search for all claims matching your search criteria. Learn more in our Checking Claim Status Quick Tip.

EDI Claim Reports

If you or your clearinghouse submit claims as HIPAA-compliant 837 files, we recommend that you retrieve and review your:

• File Detail Summary Report (277CA Report)
• Batch and Claim Level Rejection Report (the “Submitter PDF report”)
  • The report will tell you the number of claims that were:
    • Submitted
    • Accepted
    • Rejected and why.
• Functional Acknowledgement (999 Report)
• Interchange Acknowledgement (TA1)

For more information on these reports, refer to our direct connection resource, 837 Transactions - Companion Guide for Health Care Claims.

Tips

• Retain all reports you receive from your electronic claim submission to track receivables and identify potential problems.
• Resubmit corrected claims electronically. Note: Do not use frequency code 7 for claims adjudication/resubmission of claims that were rejected on the EDI front end. You must resubmit this type of claim as a new-day claim, with claim frequency = 1 (CLM05-3).

If you want to make a correction to a previously submitted 1500 or
UB-04 claim, submit a replacement claim.

If your denied claim has an error

We cannot process a claim correction and an appeal simultaneously. To avoid delays, you should:

1. Send a replacement claim first. Do not include other documentation.
   • Replacement claim exceptions appear below.
2. When we issue an updated Provider Detail Advisory, submit an appeal by sending us a completed Request for Claim Review Form with any necessary documentation. This is due within one year of the date the claim was denied.
   • Note: We do not accept appeals by phone.

When NOT to submit a replacement claim

Submit a replacement claim for all corrections except the following. You cannot use replacement claims to:

• Change or correct the:
  • Billing NPI
  • Date of service (when it falls outside the original date span)
  • Level of care (inpatient to outpatient, or vice versa)
  • Subscriber ID
• Submit for timely filing review
• Correct a bridged admission claim
• Submit claims related to accidental injuries (auto or workers’ compensation)
• Correct a claim that was part of a previous recovery. Examples:
  • Credit balance
  • Provider audit
  • Claims recovery project

For more information, refer to our Frequently Asked Questions.

Can't submit your replacement claim electronically?

Mail your:

Please do not include any additional documentation unless your claim involves Coordination of Benefits.

How to appeal

If you need to appeal rather than correct a denied claim, refer to the Claim Appeal Reference Guide and Form from Mass Collaborative. We do not accept appeals by phone.

Resources

Reviews & Appeals

 For additional details and links to tools to check the status of your claims, log in and go to Office Resources>Claim Submission.

Out-of-state providers: For claim questions, contact your local, in-state Blue plan.

Claim processing rules

Claim status check

Here are some options for both local and out-of-state BCBS Members:

• Use ConnectCenter
• Get a Direct Connection for ANSI 276/277 transactions
• Use Payspan for details on processed claims

 Quick Tip: Checking Claim Status

  Video: Checking claim status (2 min)

Claim filing timelines (timely filing requirements)

For HMO and PPO plans: Within 90 days of the date of service
For Indemnity plans: One year from the date of service

 Timely Filing Guidelines

  Video: Timely Filing Guidelines (4 min)

Claim appeals

Request for Claim Review Form and Reference Guide (masscollaborative.org)

Claim void/retraction requests

If you want to make request a full void/retraction request, you can submit a replacement claim with frequency code 8.

 Replacement Claim Requirement: Frequently Asked Questions
 Claim Resubmission Guide (Frequency Codes 7 & 8)

Submitting claims electronically

We recommend electronic claim submission for the most efficient processing. Be sure to enter the member’s ID exactly as it appears on the member’s ID card, including the prefix and all subsequent digits. For Federal Employee Program members, submit claims with a single letter "R" and the member ID number. Please make sure that your claim submission systems can accommodate a member ID with at least 17 characters, and alpha and numeric combinations. All electronic claim submissions can now accept up to 50 lines per claim.

Here are some options for submitting claims electronically:

• Through a clearinghouse/Direct Connection
  
• Direct Data Entry using ConnectCenter. (For CMS-1500 billers, we offer this tool through our website.)
  

Resources

How long it takes for a claim to process

We process most claims within 30 days of their receipt. However, in some cases, we may need additional information to process your claim. If you don’t receive final payment and claim disposition in a timely manner (within 30-45 days of our receipt of your claim), please use an electronic technology to check your claim’s status.

When we are secondary to Medicare

We have electronic claim crossover arrangements with select Medicare Administrative Contractors. When we are secondary to Medicare, you can eliminate the submission of duplicate claims by first checking claim status after you have received the Medicare Part A/Part B explanation of benefits (EOB). Please allow up to a week after you receive the Medicare EOB to confirm we have the claim.

Overpaid claims

Paper submission

Mail the:

Paper claim submission guidelines

For 1500 filing instructions, refer to the NUCC (National Uniform Claim Committee) website, nucc.org, for the 1500 Claim Form Instruction Manual.

For UB-04 billing guidelines, go to the National Uniform Billing Committee or American Hospital Association websites.

For ADA dental claim billing guidelines, refer to the ADA’s website or the Dental Blue Book.