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Page E — 1 Rev. 06/25/07

Claims Reports: Overview

Introduction

BCBSTX provides explanations of claims handling to you and the patient. There are

two reports that may be sent to your office, and they are each described in this

section.

In this

Section

This section describes the following claims reports:

Report Title Page

Provider Claim Summary for CMS 1500 (08/05) Claims E — 2

Provider Claim Summary for UB-04 Claims E — 7

Explanation of Benefits (EOB) E — 11

Rev.06/25/07 Page E — 2

Sample of Provider Claim Summary

Page E — 3 Rev. 06/25/07

Provider Claim Summary for CMS Claims

Fields

1-7

Providers receive a Provider Claims Transaction Report listing payments. The

following table explains fields 1 through 7 on this report:

Field

Number

Field Name Information Provided

1 Document Number A unique number assigned to each

Provider Claims Transaction Report.

2 NPI Number The NPI number. In a clinic or group

practice, the 800,000 number for the

provider who performed the service

will appear to the right of the patient’s

name.

3 Patient Name The patient’s name as reported to

BCBSTX.

4 Patient Account # The patient’s account number

assigned by the provider as indicated

on the claim submitted to BCBSTX. If

an account number is not given, this

field will be blank.

5 Subscriber Identification The subscriber’s identification number

from the ID card.

6 Group # The number that identifies the

subscriber’s group.

7 Claim Type This displays the code for the type of

claim.

Key for

Claim Type

Claim type code definitions:

Code Definition

ADJ Adjustment of a Previously Processed Claim

CMC Coordination of Benefits with Managed Care

COB Coordination of Benefits

MC Managed Care (optional or no PCP)

MCP Managed Care (PCP required)

MR Medicare Primary

REG Regular Business (Indemnity or ParPlan)

Continued on next page

Rev.06/25/07 Page E — 4

Provider Claim Summary for CMS Claims, Continued

Fields

8-12

The following table explains fields 8 through 12 on the Provider Claims

Transaction Report:

Field

Number


8 Internal Control

A unique number assigned to each

claim as it enters the BCBSTX claims

processing system.

9 Service Dates

The beginning and ending dates of

service indicated on the claim. If the

claim contains only one date of

service, the “To” field will be blank.

10 POS

This indicates the place of service or

where the services were performed

(e.g., office, inpatient hospital).

11 Type of Service A description of the service(s)

rendered.

12 Proc Code

The code from CPT or the BCBSTX

conversion code used to identify and

report the service performed.

Note on

Fields

11 and 12

The fields for type of service (11) and procedure code (12) will only display for

detailed line item charges where there is a difference in the total charge and the

contract allowable on claims other than Medicare-related, COB, and Adjustments.


Page E — 5 Rev. 06/25/07


Fields

13 -16

The following table explains fields 13 through 16 on the Provider Claims

Transaction Report:

Field

Number


13 Total Charges The total charges filed on the claim.

14 Contract Allowable The benefits allowed by the

subscriber’s coverage.

15 MSG Code The message code for the explanation

of the difference between the billed

charges and the contract allowable for

that procedure. Multiple message

codes may indicate that the claim was

processed with more than one type of

coverage or policy. Please see

Message Code Explanation (18).

16 Patient’s Share Listing of any copayment, deductible,

cost share (coinsurance), and charges

for medically necessary, limited, or

noncovered services.

Patient’s Share

The subscriber is responsible for no other charges submitted on the claim except for

the following:

Patient’s Share Which Includes

Copay/Deductible

The amount of copayment and/or deductible taken

from the gross allowable charges.

Coinsurance

The amount taken from the gross allowable charges

and the patient’s portion when contract benefit

percentages were applied. This includes the patient’s

benefit contract.

Other Medically necessary items not covered or limited by

the patient’s benefit contract.


Rev.06/25/07 Page E — 6


Fields

17 - 19

The following table completes the key to the Provider Claims Transaction Report:

Field

Number


17 Benefit Payment The benefit amount paid by BCBSTX

after any copay, deductibles, cost

share, and charges for medically

necessary, limited, or noncovered

services were deducted for the

contract benefit allowable amount.

18 Message Code Explanation of the difference between

the billed charge and the contract

allowable for that procedure.

19 Totals Totals for each column for all patients

included on the report.

Page E — 7 Rev. 06/25/07

Provider Claim Summary for UB-04 Claims

PROVIDER CLAIM SUMMARY

DATE: 02/10/05 1

PROVIDER NUMBER: 0000HH1234 2

CHECK NUMBER: 12345678 3

TAX IDENTIFICATION NUMBER: 123156769 4

5 COUNTY MEDICAL CENTER

P. 0. BOX 123456

YOUR CITY, TX. 12345-1234

ANY MESSAGES WILL BEGIN ON PAGE 1

*********** INPATIENT

PATIENT: HORMAN DOE PATIENT NO: 123456789 ADMIT DATE FROM DATE END DATE

CLAIM NO: 0000123456789000X CLAIM TYPE: 01/30/05 01/30/05 01/31/05

GROUP-SUB NO: FEPTX-12345678 HPI: D DRG

DAYS DRG PROVIDER OTHER PAYABLE FACILITY ADJUSTED MANAGED CARE TOTAL AMOUNT

/TRT CODE CHARGE / WITHHOLD ALLOWABLE PROV. CHARGE DEDUCTION(S) PAID

001 294 $10,816.00 $8,022.01- $2,795.99 $2,795.99 $500.00 $2,195.99

MESSAGES/REASONS: OE , OH , DRG

*** DEDUCTIONS/OTHER INELIGIBLE ***

CONTRACT DEDUCTIBLE/COPAY: $100.00

MANAGED CARE DEDUCTION(S): $500.00

TOTAL DEDUCTIONS/OTHER INELIGIBLE: ___$600.00

PATIENT'S SHARE: ___$600.00

--------------------------------------------------------------------------------

PROVIDER CLAIMS AMOUNT SUMMARY

MUMBER OF CLAIMS: 1 | AMOUNT PAID: $2,195.99

PROVIDER CHARGES: $10,618.00 | RECOUPMENT AMOUNT: $0.00

ADJUSTED PROVIDER CHARGES: $2,795.99 | NET AMOUNT AMOUNT: $2,195.99

PATIENT'S SHARE: $600.00 |

---------------------------------------------------------------------------------

CLAIM TYPE

---------------------------------------------------------------------------------

MESSAGES/REASONS:

(OE ). A CONTRACT DEDUCT I BLE/COPAY HAS BEEN TAKEN.

(OH ). PROGRAM REQUIREMENTS AS IDENTIFIED BY THE MEMBER'S CONTRACT HAVE NOT

BEEN FULFILLED. THIS IS THE PATIENT'S LIABILITY.

(DRG). THE PAYMENT ON THIS CLAIM HAS BEEN PROCESSED ACCORDING TO THE OMNIBUS

BUDGET RECONCILIATION ACT OF 1990. THE PAYMENT PROVIDED IS THE SAME

AS THE PAYMENT YOU WOULD HAVE RECEIVED HAD THE PATIENT BEEN ENROLLED

IN MEDICARE PART A. THE PAYMENT IS BASED ON THE MEDICARE DRG PRICE.

THE SUBSCRIBER IS NOT RESPONSIBLE FOR THE DIFFERENCE.

1 OF 1

Rev.06/25/07 Page E — 8

Provider Claim Summary for UB-04 Claims, Continued

Fields

1-9

The Provider Claim Summary (PCS) is a notification statement sent to contracting

providers with Blue Cross and Blue Shield of Texas (BCBSTX) after a claim has

been processed. The following table explains fields 1 through 9 on this report:

Field

Number


1 Date Date the summary was finalized.

2 NPI Number NPI Number

3 Check Number Number assigned to the check for this

summary.

4 Tax Identification Number Number which identifies provider’s

taxable income.

5 Provider or Group Name &

Address

The provider/group address where the

services were rendered.

6 Patient Name of the individual who received

the service.

7 Claim Number The Blue Cross number assigned to

the claim.

8 Group-Sub Number Number that identifies the employer

group and member.

9 Patient Number The patient’s account number

assigned by the provider.


Page E — 9 Rev. 06/25/07


Fields

10-19

The following table explains fields 10 through 19 on this report:

Field

Number


10 Claim Type Code for type of claim (benefit plan) –

see field 27.

11 HPI Indicator Blue Cross payment method for this

claim.

IND DESCRIPTION

D DRG

B Outpatient DRG Cap

W Withhold/Discount

R Case Rate

E % of charge w/cap

F Fee Schedule

P Per Diem

N Negotiated

C Inpatient Case Rate

12 Admit Date Date if admission.

13 From Date Beginning and ending dates of

services rendered.

14 End Date

15 Days/Treatment Number of days/treatment.

16 DRG Code DRG code for this type of service.

17 Provider Charge Total amount of billed charges.

18 Other Payable/Withhold Other payable amounts, such as

discounts or withholds, that affect the

adjusted provider charges.

19 Facility Allowable The provider’s allowed amount

according to negotiated contract.


Rev.06/25/07 Page E — 10


Fields

20-29

The following table explains fields 20 through 29 on this report:

Field

Number


20 Adjusted Provider Charges The allowed amount including other

payable or withhold.

21 Managed Care Deduction(s) Managed care deductions including

penalties, copayments and

coinsurance amounts.

22 Total Amount Paid The amount paid to the provider for

this service.

23 Contract Coinsurance The coinsurance/deductible amount

applied to this claim.

24 Total Deductions/Other

Ineligible

Total deductions and other ineligible

amounts.

25 Patient’s Share Amount patient pays. Providers may

bill this amount to the patient.

26 Provider Claims Amount

Summary

Total for claim(s) processed on this

summary.

27 Claim Type The description for the type of claim

in field 10.

Code Definition

Blank Traditional/Indemnity

M Managed Care

S Coordination of Benefits

T Managed Care

w/Coordination of Benefits

28 Messages/Reasons

(appears on last page of PCS)

The description for messages relating

to:

29 Messages/Reasons

Description

Non covered services

Program deductions

PPO reductions

Page E — 11 Rev. 06/25/07

Sample of Explanation of Benefits (EOB)

Rev.06/25/07 Page E — 12

Explanation of Benefits (EOB)

Fields

1 - 13

The EOB is provided to the BCBSTX subscriber and also to the provider when the

subscriber is part of an ASO (Administrative Service Only) group.

The table below provides a key to this report.

Field

Number


1 N/A The ASO Account name or the BCBSTX

logo.

2 Claim Received On The date the claim was received by

BCBSTX.

3 N/A The date the claim was paid.

4 Subscriber The subscriber’s name will appear here.

5 Patient The patient’s name as reported to BCBSTX

on the claim submitted.

6 Subscriber ID The subscriber’s identification number from

the ID card.

7 Group Number Number that identifies the subscriber’s group

listed on the ID card.

8 Control Number A unique number assigned to each claim as it

enters the BCBSTX claims processing

system.

9 Dates of Service The beginning and ending dates of service

indicated on the claim. If the claim contains a

single date of service, the “To” column will

be blank.

10 Provider Physician’s or other provider’s name.

11 Type of Service A general description of the service provided.

12 Charges Submitted Amount billed on the claim submitted to

BCBSTX.

13 Eligible Charges Amount of charges billed that are allowed

under the subscriber’s benefit plan.


Page E — 13 Rev. 06/25/07

Explanation of Benefits (EOB), Continued

Fields

14a – 14e

The following table explains field 14a-14e “Your Responsibility” or the patient’s

share:

Field

Number


14a Noncovered The amount for any services not covered by

the subscriber’s benefit plan.

14b Copay Amount of payment the subscriber makes at

the time services are provided, if indicated by

the subscriber’s benefit plan.

14c Deductible The amount of eligible expenses that the

subscriber is responsible for before benefits

will be available.

14d Cost Share The portion of covered expenses the

(Coinsurance) subscriber pays after the

deductible has been satisfied.

14e Your Total This is the total amount the subscriber is

responsible for based on the charges

submitted. This total includes any amounts

the subscriber may have previously paid to

the provider.

Fields

15 - 16

The table below continues the EOB key:

15 Your Benefit The amount that is payable on the Plan Pays

claim submitted to BCBSTX. This is the

amount of payment issued to the BlueChoice

Network provider.

16 Explanations An alpha code matching a narrative

explanation listed at field 18.


Rev.06/25/07 Page E — 14

Explanation of Benefits (EOB), Continued

Fields

17 – 21

The table below completes the EOB key:

Field

Number


17 Totals The totals of each of the following columns:

• Charges Submitted

• Eligible Charges

• Noncovered

• Copay

• Deductible

• Cost Share

• Benefit Plan Pays

18 Explanations: This is a narrative describing claims

processing.

19 N/A Deductible/Cost Share/Year-to-

Date/Maximum information will be listed

here. This is a summary of subscriber liability

for cost share and/or deductible, if applicable

to this claim.

20 N/A Customer Service address and telephone

numbers will be displayed here. Inquiries

regarding claims processing would be

handled at this address or telephone number.

21 N/A When payment is made, the check is attached

here. (One check per ASO subscriber.)

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