This article is for all providers caring for Federal Employee Program members, including, but not limited to:
- Acute care hospitals discharging maternity patients postpartum
- Freestanding clinical laboratories
- Ground ambulance providers
- Lactation counselors
We’re noticing a trend in denied claims, leading to an increase in appeals for Federal Employee Program (FEP) members.
Below, you’ll find steps you can take to help your claims process smoothly for the topics listed. We hope this reduces your administrative time spent on claim appeals and decreases confusion for members about their coverage and health care costs.
Remember, you can recognize an FEP member by the “R” prefix, followed by eight digits, on their member ID card.
What’s the trend? Providers are submitting replacement claims without submitting a fully corrected claim. We’re seeing replacement claims submitted with only the newly corrected codes that weren’t on the original claim. All of the other information that was on the original claim that is correct is missing. This causes us to process the claim with the new information only, which isn’t always your intent.
What can you do?
- Be sure your replacement claim includes all codes for the date of service you’re billing us for. Please remember that by submitting a replacement claim, you are doing just that—replacing the complete claim. Therefore, all services should be included.
- Review our replacement claim resources.
What’s the trend? We’re seeing an increase in split billing and claims that don’t match the approved authorization. In some cases, labs are getting multiple prior authorizations for the same date and same service and submitting multiple claims.
What can you do?
- All services rendered by the same provider on the same date of service should be submitted on a single claim.
- Review the authorization approval for the service and make sure it matches the claim.
What’s the trend? Blue Cross Blue Shield of Massachusetts is receiving ground ambulance claims that should have been sent to the state where the service was rendered. Transport claims are also missing correct modifiers.
What can you do?
- Submit claims with appropriate modifiers for pick-up and drop-off locations. Refer to our Ambulance Transportation payment policy for a list.
- Submit claims with appropriate modifiers for pick-up and drop-off locations. Refer to our Ambulance Transportation payment policy for a list. Log in and go to Office Resources>Policies & Guidelines>Payment Policies.
- Send your claim to the Blue Cross Blue Shield plan of the state where services were rendered and where the member was picked up for transport. For example, if the FEP member is picked up in Rhode Island and is taken to a Massachusetts facility, you should submit the claim to Blue Cross Blue Shield of Rhode Island.
What’s the trend? When postpartum members are discharged from the hospital, they are often referred to virtual lactation counseling services with providers that aren’t covered by their telehealth benefits. FEP members do not have benefits to receive lactation counseling via telehealth from providers in our network.
What can you do?
- Review FEP member coverage by visiting fepblue.org.
- Refer them to Teladoc Health®' or refer them for in-person visits from network providers, both of which are covered.
Thank you!
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