Copyright 2023 Providence Health Plan, Providence Plan Partners, and Providence Health Assurance. A request for payment that you or your health care Provider submits to Providence when you get drugs, medical devices, or receive Covered Services. If your appeal involves (a) medically necessary treatment, (b) experimental investigational treatment, (c) an active course of treatment for purposes of continuity of care, (d) whether a course of treatment is delivered in an appropriate setting at an appropriate level of care, or (e) an exception to a prescription drug formulary, you may waive your right to internal appeal and request an external review by an Independent Review Organization. Media. You may send a complaint to us in writing or by calling Customer Service. If your prescribing physician asks for a faster decision for you, or supports you in asking for one by stating (in writing or through a phone call to us) that he or she agrees that waiting 72 hours could seriously harm your life, health or ability to regain maximum function, we will give you a decision within 24 hours. Congestive Heart Failure. | October 14, 2022. If an ongoing course of treatment for you has been approved by Providence and it then determines through its medical cost management procedures to reduce or terminate that course of treatment, you will be provided with advance notice of that decision. If your premium is not received by the last day of the month, you will enter a grace period which begins retroactively on the first of the month. Stay up to date on what's happening from Bonners Ferry to Boise. Reimbursement policy. Services provided by out-of-network providers. To request or check the status of a redetermination (appeal). Our clinical team of experts will review the prior authorization request to ensure it meets current evidence-based coverage guidelines. The following information is provided to help you access care under your health insurance plan. Understanding our claims and billing processes. If you wish to appoint someone to act on your behalf, you must complete an appointment of representative form and send it to us with your prescription coverage determination form. If they are not met, a denial letter is sent to the member and the provider explaining why the service is not covered and how to appeal the claim denial. People with a hearing or speech disability can contact us using TTY: 711. If you disagree with our decision about your medical bills, you have the right to appeal. The quality of care you received from a provider or facility. Claims Submission. Disclaimer |Non-discrimination and Communication Assistance |Notice of Privacy Practice |Terms of Use & Privacy Policy, Providence Health Plan, 3601 SW Murray Blvd., Suite 10, Beaverton, Oregon 97005(if mailing, use only the post office box address listed above). Copayment means the fixed dollar amount that you are responsible for paying to a health care Provider when you receive certain Covered Services, as shown in the Benefit Summary. You can submit a marketing complaint to us by calling the phone number on the back of your member ID card or by calling 1-800-MEDICARE (1-800-633-4227). You have the right to file a grievance, or complaint, about us or one of our plan providers for matters other than payment or coverage disputes. Claims are processed according to the benefits, rules, guidelines and regulations of the federal government, which supersede state laws. Better outcomes. Contact Availity. Coordinated Care Organization Timely Filing Guidance The Oregon Health Authority (OHA) has become aware of a possible issue surrounding the coordinated care organization (CCO) contract language in Section 5(b) Exhibit B Part 8 which states . Denials with solutions in Medical Billing, Denials Management Causes of denials and solution in medical billing, CO 4 Denial Code The procedure code is inconsistent with the modifier used or a required modifier is missing, CO 5 Denial Code The Procedure code/Bill Type is inconsistent with the Place of Service, CO 6 Denial Code The Procedure/revenue code is inconsistent with the patients age, CO 7 Denial Code The Procedure/revenue code is inconsistent with the patients gender, CO 15 Denial Code The authorization number is missing, invalid, or does not apply to the billed services or provider, CO 17 Denial Code Requested information was not provided or was insufficient/incomplete, CO 19 Denial Code This is a work-related injury/illness and thus the liability of the Workers Compensation Carrier, CO 23 Denial Code The impact of prior payer(s) adjudication including payments and/or adjustments, CO 31 Denial Code- Patient cannot be identified as our insured, CO 119 Denial Code Benefit maximum for this time period or occurrence has been reached or exhausted, Molina Healthcare Phone Number claims address of Medicare and Medicaid, Healthfirst Customer Service-Health First Provider Phone Number-Address and Timely Filing Limit, Kaiser Permanente Phone Number Claims address and Timely Filing Limit, Amerihealth Caritas Phone Number, Payer ID and Claim address, ICD 10 Code for Sepsis Severe Sepsis and Septic shock with examples, Anthem Blue Cross Blue Shield Timely filing limit BCBS TFL List, Workers Compensation Insurances List of United States, Workers Compensation time limit for filing Claim and reporting in United States. Pennsylvania. Services or supplies your medical care Provider needs to diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine. Regence BlueCross BlueShield of Oregon offers health and dental coverage to 750,000 members throughout the state. You may purchase up to a 90-day supply of each maintenance drug at one time using a Participating mail service or preferred retail Pharmacy. The following Out-of-Pocket costs do not apply toward your Out-of-Pocket Maximum: A claim that requires further information or Premium payment before it can be fully processed and paid to the health care Provider. Expedited determinations will be made within 24 hours of receipt. Clean claims will be processed within 30 days of receipt of your Claim. Non-discrimination and Communication Assistance |. Requests to find out if a medical service or procedure is covered. Obtain this information by: Using RGA's secure Provider Services Portal. We probably would not pay for that treatment. 2023 Regence health plans are Independent Licensees of the Blue Cross and Blue Shield Association serving members in Idaho, Oregon, Utah and select counties of Washington. Claims received after 12 months will be denied for timely filing and the OGB member and Blue Cross should be held harmless. The front of the member ID cards include the: National Account BlueCross BlueShield logo, .css-1u32lhv{max-width:100%;max-height:100vh;}.css-y2rnvf{display:block;margin:16px 16px 16px 0;}. State Lookup. 1/23) Change Healthcare is an independent third-party . The total amount you will pay Out-of-Pocket in any Calendar Year for Covered Services received. If you want more information on how to obtain prior authorization, please call Customer Service at 800-638-0449. Your Provider or you will then have 48 hours to submit the additional information. If you are hearing impaired and use a Teletype (TTY) Device, please call our TTY line at 711. 1/2022) v1. You're the heart of our members' health care. What is Medical Billing and Medical Billing process steps in USA? Tweets & replies. Your Coinsurance for a Covered Service is shown in the Benefit Summary, and is a percentage of the charges for the Covered Service. You have the right to make a complaint if we ask you to leave our plan. For Example: ABC, A2B, 2AB, 2A2 etc. Once a final determination is made, you will be sent a written explanation of our decision. View sample member ID cards. Telehealth services are provided to member, claim is submitted to Blue Cross of Idaho. 639 Following. Deductibles, Copayments or Coinsurance for a Covered Service if indicated in any Benefit Summary as not applicable to the Out-of-Pocket Maximum. We will accept verbal expedited appeals. RGA claims that are submitted incorrectly to Regence will be returned with instructions to resubmit to the correct payer. Regence BlueShield Attn: UMP Claims P.O. The member can appeal, or a representative the member chooses, including an attorney or, in some cases, a doctor. Payment of all Claims will be made within the time limits required by Oregon law. Prior Authorized determinations are not a guarantee of benefit payment unless: A physician, Womens Health Care Provider, nurse practitioner, naturopath, clinical social worker, physician assistant, psychologist, dentist, or other practitioner who is professionally licensed by the appropriate governmental agency to diagnose or treat an injury or illness and who provides Covered Services within the scope of that license. Company information about the Regence Group-BlueCross BlueShield affiliated health care plans located in Oregon, Washington, Utah and Idaho, and serving more than 3 million subscribers. Contacting RGA's Customer Service department at 1 (866) 738-3924. For nonparticipating providers 15 months from the date of service. If an Out-of-Network Provider charges more than your plan allows, that Provider may bill you directly for the additional amount. 2018 Regence BlueCross BlueShield of Utah Member Reimbursement Form Author: Regence BlueCross BlueShield of Utah Subject: 2018 Regence BlueCross BlueShield of Utah Member Reimbursement Form Keywords: 2018, Regence, BlueCross, BlueShield, Utah, Member, Reimbursement, Form, PD020-UT Created Date: 10/23/2018 7:41:33 AM All Rights Reserved. Please present your Member ID Card to the Participating Pharmacy at the time you request Services. State Lookup. Appeal: 60 days from previous decision. . The Blue Cross and Blue Shield Service Benefit Plan, also known as the BCBS Federal Employee Program (BCBS FEP), has been part of the Federal Employees Health Benefits Program (FEHBP) since its inception in 1960. Timely Filing Rule. provider to provide timely UM notification, or if the services do not . Y2B. The 35 local member companies of the Blue Cross Blue Shield Association are the primary points of contact for Service Benefit Plan members. If you have questions about any of the information listed below, please call customer service at 503-574-7500 or 800-878-4445. A single payment may be generated to clinics with separate remittance advices for each provider within the practice. Claims, correspondence, prior authorization requests (except pharmacy) Premera Blue Cross Blue Shield of Alaska - FEP. Care Management Programs. Blue Cross Blue Shield Federal Phone Number. To obtain prescriptions by mail, your physician or Provider can call in or electronically send the prescription, or you can mail your prescription along with your Providence Member ID number to one of our Network mail-order Pharmacies. A tax credit you may be eligible for to lower your monthly health insurance payment (or Premium). If you pay your Premiums in full before the date specified in the notice of delinquency, your coverage will remain in force and Providence will pay all eligible Pended Claims according to the terms of your coverage. The Centers for Medicare & Medicaid Services values your feedback and will use it to continue to improve the quality of the Medicare program.. You can submit a marketing complaint to us by calling the phone number on the back of your member ID card or by calling 1-800-MEDICARE (1-800-633-4227). Anthem Blue Cross and Blue Shield Serving Hoosier Healthwise, Healthy Indiana Plan and Hoosier Care Connect June 12, 2018 . Mail your claim and supporting document(s) to the address below: Alternatively, you may send the information by fax to, Have your knowledge and agreement while receiving the Service, Be prescribed and approved by your Provider; and. Pennsylvania. If this happens, you will need to pay full price for your prescription at the time of purchase. The Blue Cross Blue Shield Association negotiates annually with the U.S. Office of Personnel Management (OPM) to determine the benefits and premiums for the Blue Cross and Blue Shield Service Benefit Plan. Browse value-added services & buy-up options, Prescription Drug reimbursement request form, General Medical Prior Authorization Fax Form, Carelon Medical Benefits Management (formerly AIM Specialty Health). Participating Pharmacies may not charge you more than your Copayment of Coinsurance, except when Deductible and/or coverage limitations apply. Providence will then notify you of its reconsideration decision within 24 hours after your request is received. If your Provider bills you directly, and you pay for Services covered by your plan, we will reimburse you if you send us your claims information in writing. Durable medical equipment, including but not limited to: Certain infused prescription drugs administered in a hospital-based infusion center, Member ID number and plan number (refer to your member ID card), Provider name, address and telephone number, Date of admission or date services are to begin, Mail it to: Providence Health Plan, Appeals and Grievances Department, PO Box 4158, Portland, Oregon 97208-4158. BCBSWY News, BCBSWY Press Releases. Providence will notify you if an approved ongoing course of treatment is reduced or ended because of a medical cost management decision. Learn more about billing and how to submit claims to us for payment, including claims for BlueCross and BlueShield Federal Employee Program (BCBS FEP) members. To qualify for expedited review, the request must be based upon urgent circumstances. Usually we will send you an Explanation of Benefits (EOB) statement or a letter explaining our decision about a pre-authorization request. We may not pay for the extra day. Regence BlueCross BlueShield of Utah is an independent licensee of the Blue Cross and Blue Shield Association. BCBS Prefix will not only have numbers and the digits 0 and 1. Regence is the name given to Blue Cross and Blue Shield plans in four northwestern states. We know it is essential for you to receive payment promptly. The Blue Cross and/or Blue Shield Plans comprising The Regence Group serve Idaho, Oregon, Utah and much of Washington state If we need additional information to complete the processing of your Claim, the notice of delay will state the additional information needed, and you (or your provider) will have 45 days to submit the additional information. Providence will complete its review and notify the requesting provider or you of its decision by the earlier of (a) 48 hours after the additional information is received or, (b) if no additional information is provided, 48 hours after the additional information was due. Submit pre-authorization requests via Availity Essentials. You go to a hospital emergency room to have stitches removed, rather than wait for an appointment in your doctors office. To request reimbursement, you will need to fill out and send Providence a Prescription Drug reimbursement request form. Completion of the credentialing process takes 30-60 days. Provider Home. See the complete list of services that require prior authorization here. If you have questions, contact Premera at 1 (855) 784-4563 (TRS: 711) Monday through Friday 7 a.m. to 5 p.m. (Pacific). http://www.insurance.oregon.gov/consumer/consumer.html. Prior authorization is not a guarantee of coverage. Use the appeal form below. If you choose a brand-name drug when a generic-equivalent is available, any difference in cost for Prescription Drug Covered Services will not apply to your Calendar Year Deductibles and Out-of-Pocket Maximums. e. Upon receipt of a timely filing fee, we will provide to the External Review . Timely filing limits may vary by state, product and employer groups. Regence Claim Number(s)* List the specific CPT/HCPCS you are appealing* Date(s) of Service* Member ID Number (prefix/member ID)* Patient Name* Patient Date of Birth* Total Billed Amount* 5255OR - Page 1 of 2 (Eff. Claim filed past the filing limit. If you are seeking services from an out-of-network provider or facility at contracted rates, a prior authorization is required. Regence Group Administrators (RGA) is a wholly owned subsidiary of Regence that provides third-party administrative services to self-funded employer groups primarily located in Oregon and Washington. Certain Covered Services, such as most preventive care, are covered without a Deductible. During the first month of the grace period, Providence will pay Claims for your Covered Services received during that time. If the Premium is not paid by the last day of the grace period specified in the notice, your coverage will be terminated with no further notice on the last day of the month through which Premium was paid. You can use Availity to submit and check the status of all your claims and much more. Independence Blue-Cross of Philadelphia and Southeastern Pennsylvania. All hospital and birthing center admissions for maternity/delivery services, Inpatient rehabilitation facility admissions, Inpatient mental health and/or chemical dependency services, Procedures, surgeries, treatments which may be considered investigational. Once we receive the additional information, we will complete processing the Claim within 30 days. 2023 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. MPC_062416-2M (rev. Within two business days of the receipt of the additional information, Providence will complete its review and notify you and your Provider of its decision. If Providence needs additional information to complete its review, it will notify your Provider or you within 24 hours after the request is received. If additional information is needed to process the request, Providence will notify you and your provider. Learn how to identify our members coverage, easily submit claims and receive payment for services and supplies. Does United Healthcare cover the cost of dental implants? Within each section, claims are sorted by network, patient name and claim number. A retroactive denial may result in Providence asking you or your Provider to refund the Claim payment. Codes billed by line item and then, if applicable, the code(s) bundled into them. In addition, you cannot obtain a brand-name drug for the copayment that applies to the generic drug. Since 1958, AmeriBen has offered experienced services in Human Resource Consulting and Management, Third Party Administration, and Retirement Benefits Administration. Case management information for physicians, hospitals, and other health care providers in Oregon who are part of Regence BlueCross BlueShield of Oregon's provider directory. Please include the newborn's name, if known, when submitting a claim. You are essential to the health and well-being of our Member community. Oregon Help Center: Important contact information for Regence BlueCross BlueShield Oregon. Enrollment in Providence Health Assurance depends on contract renewal. You are about to leave regence.com and enter another website that is not affiliated with or licensed by the Blue Cross Blue Shield Association. EvergreenHealth has notified us of their intent to end their contract with Premera Blue Cross on March 31, 2023. Appeal form (PDF): Use this form to make your written appeal. . Learn more about when, and how, to submit claim attachments. We may use or share your information with others to help manage your health care. Out-of-network providers may not, in which case you will need to submit any needed requests for prior authorization. All FEP member numbers start with the letter "R", followed by eight numerical digits. Your request for external review must be made to Providence Health Plan in writing within 180 days of the date on the Explanation of Benefits, or that decision will become final. Coordination of Benefits, Medicare crossover and other party liability or subrogation. Your Plan only pays for Covered Services received from approved, Prior Authorized Out-of-Network Providers at rates allowed under your plan. Definitions "Appeal" includes any grievance, complaint, reconsideration or similar terms as used in some jurisdictions, and is a written or oral request from a member, their pers onal representative, treating provider or appeal representative, to change a previous decision (Adverse Benefit Coverage is subject to the medical cost management protocols established by Providence to make sure Covered Services are cost effective and meet our standards of quality. A policyholder shall be age 18 or older. Box 1106 Lewiston, ID 83501-1106 Fax: 1 (877) . A list of covered prescription drugs can be found in the Prescription Drug Formulary. Learn about submitting claims. If Providence denies your claim, the EOB will contain an explanation of the denial. Denials with solutions in Medical Billing, Denials Management Causes of denials and solution in medical billing, CO 4 Denial Code The procedure code is inconsistent with the modifier used or a required modifier is missing, CO 5 Denial Code The Procedure code/Bill Type is inconsistent with the Place of Service, CO 6 Denial Code The Procedure/revenue code is inconsistent with the patients age, CO 7 Denial Code The Procedure/revenue code is inconsistent with the patients gender, CO 15 Denial Code The authorization number is missing, invalid, or does not apply to the billed services or provider, CO 17 Denial Code Requested information was not provided or was insufficient/incomplete, CO 19 Denial Code This is a work-related injury/illness and thus the liability of the Workers Compensation Carrier, CO 23 Denial Code The impact of prior payer(s) adjudication including payments and/or adjustments, CO 31 Denial Code- Patient cannot be identified as our insured, CO 119 Denial Code Benefit maximum for this time period or occurrence has been reached or exhausted, Molina Healthcare Phone Number claims address of Medicare and Medicaid, Healthfirst Customer Service-Health First Provider Phone Number-Address and Timely Filing Limit, Kaiser Permanente Phone Number Claims address and Timely Filing Limit, Amerihealth Caritas Phone Number, Payer ID and Claim address, ICD 10 Code for Sepsis Severe Sepsis and Septic shock with examples, Anthem Blue Cross Blue Shield Timely filing limit BCBS TFL List, Workers Compensation Insurances List of United States, Workers Compensation time limit for filing Claim and reporting in United States. Payments for most Services are made directly to Providers. Please see your Benefit Summary for information about these Services. If you are seeing a non-participating provider, you should contact that providers office and arrange for the necessary records to be forwarded to us for review. Previously, the corrected claims timely filing standard was the following: For participating providers 90 days from the date of service. After receiving the additional information, Providence will complete its review and notify you and your Provider or just you of its decision within two business days. Provider temporarily relocates to Yuma, Arizona. Under no circumstances (with the exception of Emergency and Urgent Care) will we cover Services received from an Out-of-Network Provider/Facility unless we have Prior Authorized the Out-of-Network Provider/Facility and the Services received. . Copayments or Coinsurance specified as not applicable toward the Deductible in the Benefit Summary. If you are deaf, hard of hearing, or have a speech disability, dial 711 for TTY relay services. You are about to leave regence.com and enter another website that is not affiliated with or licensed by the Blue Cross Blue Shield Association. Although a treatment was prescribed or performed by a Provider, it does not necessarily mean that it is Medically Necessary under our guidelines. rule related to timely filing is found in OAR 410-120-1300 and states in part that Medicaid FFS-only . You can submit feedback about your Medicare health plan or prescription drug plan directly to Medicare. Read More. View reimbursement policies. Filing your claims should be simple. Reimbursement policy documents our payment policy and correct coding for medical and surgical services and supplies. Copayment or Coinsurance amounts, Deductible amounts, Services or amounts not covered and general information about our processing of your Claim are explained on an EOB. 276/277. Such protocols may include Prior Authorization*, concurrent review, case management and disease management. Reconsideration: 180 Days. i. For expedited requests, Providence will notify your Provider or you of its decision within 24 hours after receipt of the request. Diabetes. 225-5336 or toll-free at 1 (800) 452-7278. Please see Appeal and External Review Rights. Claims for your patients are reported on a payment voucher and generated weekly. Submit claims to RGA electronically or via paper. If claim history states the claim was submitted to wrong insurance or submitted to the correct insurance but not received, appeal the claim with screen shots of submission as proof of timely filing(POTF) and copy of clearing house acknowledgement report can also be used. Our right of recovery applies to any excess benefit, including, but not limited to, benefits obtained through fraud, error, or duplicate coverage relating to any Member. If you fail to obtain a Prior Authorization when it is required, any claims for the services that require Prior Authorization may be denied. 2023 Regence health plans are Independent Licensees of the Blue Cross and Blue Shield Association serving members in Idaho, Oregon, Utah and select counties of Washington. You may only disenroll or switch prescription drug plans under certain circumstances. We will make an exception if we receive documentation that you were legally incapacitated during that time. 601 SW Second Avenue Portland, Oregon 97204-3156 503-765-3521 or 888-788-9821 Visit our website: www.eocco.com Eastern Oregon Coordinated Care Organization We will notify you once your application has been approved or if additional information is needed. 1-800-962-2731. Please contact the Medicare Appeals Team at 1 (866) 749-0355 or submit the appeal in writing and stating you need a fast, expedited, or hot" review, or a similar notation on the paperwork. When you provide covered services to a Blue Shield member, you must submit your claims to Blue Shield within 12 months of the date of service(s) unless otherwise stated by contract. TTY/TDD users can call 1-877-486-2048, 24 hours a day/7 days a week. Benefits are not assignable; you will receive direct payment even if your patient signs an assignment authorization. If claims submitted after the timely frame set by insurances, then those claims will be denied by insurance companies as CO 29-The time limit for filing has expired. A determination that relates to benefit coverage and Medical Necessity is obtained no more than 30 days prior to the date of the Service; or. Offer a medical therapeutic value at least equal to the Covered Service that would otherwise be performed or given. Prescription drugs must be purchased at one of our network pharmacies. Call the phone number on the back of your member ID card. Services that are not considered Medically Necessary will not be covered. An appeal is a request from a member, or an authorized representative, to change a decision we have made about: Other matters included in your plan's contract with us or as required by state or federal law, Someone who has insurance through an employer, and any dependents they choose to enroll. Learn more about our payment and dispute (appeals) processes. Oregon Help Center: Important contact information for Regence BlueCross BlueShield Oregon.