Rochester New York Blue Cross and Blue Choice

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Complete all required areas of the UB-04 claim form.

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Use only original UB-04 claim forms with the red drop-out ink or file electronically.

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When using a printer, make sure the form is lined up correctly to facilitate electronic scanning.

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The value for all check boxes on the form is X.

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If a field is not completed, leave the items empty on the form.

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Do not enter zeros into numeric fields; leave the numeric fields empty unless specified.

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Claims are split into items based on the Revenue/HCPC Codes.

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Type – C (Commercial)

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Mode – R (Regular)

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Form – UB-04

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In the IDs to include in Paper Claims section, select the Legacy IDs and National Provider IDs (NPI) check box.

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In the IDs to include in EMC files section, select the National Provider IDs (NPI) check box.

Locator

Locator Name

Setup

N/A

Specialized Formats

Make no selection.

N/A

Printer

Select the appropriate printer.

N/A

General Rules

Select the Suppress dots & dashes in ICD codes, dates and insured info print variation.

FL 4

Type of Bill

Enter 0 to indicate the four-digit Type of Bill using the claim constants at the appropriate level.

FL 8

Patient Name

Select the Print Insurance ID print variation.

FL 18–28

Condition Code

If needed, enter condition codes in Patient>General>Claim Constants.

FL 31ab–34ab

Occurrence Code

If needed, enter occurrence codes in Patient>General>Claim Constants.

FL 35ab–36ab

Occurrence Span Codes

If needed, enter occurrence span codes in Patient>General>Claim Constants.

FL 39 –41

Value Codes Amounts

Enter value codes and the total charge amount of a claim in Patient>General>Claim Constants.

FL 42

Revenue Code

Enter the appropriate revenue codes in the Rev Code column in Administration>Financial>Billing Rates>Rates for this insurance.

FL 44

HCPCS/Rate/HIPPS Code

If needed, enter HCPCS codes in the HCPCS/HIPPS Code field in Administration>Financial>Billing Rates. Also, include any modifiers in positions 6–7, 8–9, and 10–11 of this field.

FL 52–53

Release of Information Certification Indicator

Select the Print 'Y' in release and info print variation.

FL 59

Patient's Relationship to Insured

Select the Suppress printing of Patient Relationship print variation.

FL 69

Admit Diagnosis

Select the Print the patient's diagnosis code as of the patient's admission date print variation.

FL 80

Remarks

If needed, enter remarks in Patient>General>Claim Constants.

FL 81

Code – Code Field

Select the Print agency's taxonomy and B3 qualifier print variation.

Field

Description

Assignment of Benefits

and

Release of Information

In Patient>General>Payers>HIPAA, the Assign Benefits (Assignment of Benefits) and Rel Infor (Release of Information) fields are currently set to Y by default for each carrier. Change to N where applicable.

Agency Federal Tax ID

Enter the agency's federal tax ID in the Federal Tax ID column in Administration>Configuration>Business Units>Teams and Legal Entities>Legal Entities.

Federal Tax ID

-OR-

Social Security Number

For the patient's attending physician and referring physician, enter either the physician's federal tax ID or Social Security Number in Resource>General>Roles. 
Note: If the Federal Tax ID field in Resource>General>Roles is empty, the application reports 999999999 as the tax ID.

Insurance Type Code

Select the appropriate code identifying the type of insurance policy within a specific insurance program in the Insurance Type Code field in Administration>Financial>Insurance Codes>General and/or Administration>Financial>Insurance Companies>Company.

Medicare Assign (Medicare Assignment Code)

If the code other than the default A (Assigned) is selected in the Medicare Assign field in Patient>General>Payers>HIPAA, then C (Not Assigned) will print to the claim file.

Patient Sign (Patient Signature Code)

If the Rel Infor (Release of Information) field in Patient>General>Payers>HIPAA is set to Y, select the appropriate patient signature code, if different from the default code of B (Signed authorization form for CMS-1500 (08/05), Block 12/13 on file).

Program (Special Program Code)

In Patient>General>Payers>Pay Source>HIPAA, select 01 (EPSDT) if the services are provided under the EPSDT problem.

Receiver ID (File Recipient)

Enter 00304 in the Receiver ID (File Recipient) field in Administration>Financial>Insurance Codes>EMC.

Receiver Name (Payer)

Enter BCBSRA in the Receiver Name (Payer) field in Administration>Financial>Insurance Codes>EMC.

Secondary Provider ID Number

If you have a secondary other payer ID code, enter this code in the Secondary No./Locator Code field in Administration>Financial>Insurance Codes>General. Otherwise, enter BCBSRA in the Receiver ID field in Administration>Financial>Insurance Codes>EMC.

Submitter ID

Enter the agency's Rochester sender ID in the Submitter ID field in Administration>Financial>Insurance Codes>EMC.

Test Submission Indicator

Select the Test Submission Indicator check box in Administration>Financial>Insurance Codes>EMC to indicate if this is a test file being sent.

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In Administration>Financial>Insurance Codes>Print Variations, select the check box under FL 14–15 to ensure the ANSI 5010 Billing Template compliance.

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Ensure that either I or Y is selected for ANSI 5010 in the Rel Infor(Release of Information) field in Patient>General>Payers>HIPAA.

Field

Description

Assignment of Benefits

and

Release of Information

In Patient>General>Payers>HIPAA, the Assign Benefits (Assignment of Benefits) and Rel Infor (Release of Information) fields are currently set to Y by default for each carrier. Change to N where applicable.

Agency Federal Tax ID

Enter the agency's federal tax ID in the Federal Tax ID column in Administration>Configuration>Business Units>Teams and Legal Entities>Legal Entities.

Federal Tax ID

-OR-

Social Security Number

For the patient's attending physician and referring physician, enter either the physician's federal tax ID or Social Security Number in Resource>General>Roles. 
Note: If the Federal Tax ID field in Resource>General>Roles is empty, the application reports 999999999 as the tax ID.

Insurance Type Code

Select the appropriate code identifying the type of insurance policy within a specific insurance program in the Insurance Type Code field in Administration>Financial>Insurance Codes>General and/or Administration>Financial>Insurance Companies>Company.

Medicare Assign (Medicare Assignment Code)

If the code other than the default A (Assigned) is selected in the Medicare Assign field in Patient>General>Payers>HIPAA, then C (Not Assigned) will print to the claim file.

Patient Sign (Patient Signature Code)

If the Rel Infor (Release of Information) field in Patient>General>Payers>HIPAA is set to Y, select the appropriate patient signature code, if different from the default code of B (Signed authorization form for CMS-1500 (08/05), Block 12/13 on file).

Program (Special Program Code)

In Patient>General>Payers>Pay Source>HIPAA, select 01 (EPSDT) if the services are provided under the EPSDT problem.

Receiver ID (File Recipient)

Enter 00304 in the Receiver ID (File Recipient) field in Administration>Financial>Insurance Codes>EMC.

Receiver Name (Payer)

Enter BCBSRA in the Receiver Name (Payer) field in Administration>Financial>Insurance Codes>EMC.

Secondary Provider ID Number

If you have a secondary other payer ID code, enter this code in the Secondary Provider ID field in Administration>Financial>Insurance Companies>Company. Otherwise, enter BCBSRA in the Receiver ID field in Administration>Financial>Insurance Codes>EMC.

Submitter ID

Enter the agency's Rochester sender ID in the Submitter ID field in Administration>Financial>Insurance Codes>EMC.

Test Submission Indicator

Select the Test Submission Indicator check box in Administration>Financial>Insurance Codes>EMC to indicate if this is a test file being sent.

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Detail Line Reporting, No Summary

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Group details (visits and supplies) by Item Date, Revenue Code, HCPCS/CPT, and Description

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Sort details by Item Date, Revenue Code, HCPCS/CPT, and Description

Locator

Setup

General Rules

Select the following print variations:

FL 1

Select the Check box 7 for Other print variation.

FL 2

Select the Print 'SAME' when patient is the insured print variation.

FL 6

Select the Suppress printing of Patient Relationship print variation.

FL 7

Select the Print 'SAME' when patient is the insured print variation.

FL 12

Select the following print variations:

FL 13

Select the Print 'Signature on File' and date print variation.

FL 19

Select the Print 'VOID' for voided claims print variation.

FL 22

Select the Print the Transaction Control Number (TCN) of original claim print variation.

FL 24J

Select the Print agency's NPI print variation.

FL 27

Select the Print an 'X' in 'Yes' print variation.

FL 31

Select the Print 'SIGNATURE ON FILE' and Date print variation.

FL 33

Select the Print the agency name, address and phone number print variation.

FL 33b

Select the Print the Taxonomy Code and ZZ Qualifier of the provider print variation.

Field

Description

Assignment of Benefits

and

Release of Information

In Patient>General>Payers>HIPAA, the Assign Benefits (Assignment of Benefits) and Rel Infor (Release of Information) fields are currently set to Yby default for each carrier. Change to N where applicable.

Federal Tax ID

-OR-

Social Security Number

-AND-

Provider Taxonomy Code

-AND-
NPI

If your commercial carrier requires to report an attending physician:

In addition, the values from the State License, UPIN, and Additional Physician fields may also be reported.

These fields are located in Resource>General>Roles.

Medicare Assign (Medicare Assignment Code)

Enter A or C in Patient>General>Payers>Pay Source>HIPAA. If selected, B is converted to A, and P is converted to C.

Payer Claim Office #

If required by your carrier, indicate the claim office number to which the claim will be sent in the Payer Claim Office # field in Administration>Financial>Insurance Companies>Company.

Payer IDs

Associate each insurance carrier with payer IDs from the carrier to which you will be submitting claims for Rochester (NY) in Administration>Financial>Ins Clearinghouse>Payer IDs.

Permitted Home Health Activity

Select the type of permitted Home Health activity different from Other to submit the information in the electronic file because Other is not a valid value under HIPAA.

Provider ID

Enter the organization's carrier-assigned provider number in the Provider ID field in Administration>Financial>Insurance Companies>Company.

Provider ID Type

To meet HIPAA requirements, for commercial carriers that are Blue Cross/Blue Shield, specify if the provider ID (entered in the Provider ID field) is Blue Cross or Blue Shield in the Provider ID Type field in Administration>Financial>Insurance Companies>Company.

Provider Taxonomy Code

Enter the agency's provider taxonomy code in the Provider Taxonomy Code field in Administration>Financial>Insurance Codes>General or in Administration>Financial>Insurance Companies>Company.

Submitter ID

Enter value provided to you for this payer or this payer's carrier in the Submitter ID field in Administration>Financial>Insurance Codes>EMC.

Receiver ID

Enter the value provided to you for this payer or this payer's carrier in the Receiver ID field in Administration>Financial>Insurance Codes>EMC.

Receiver Name

Enter EXCELLUS in the Receiver Name field in Administration>Financial>Insurance Codes>EMC.

Request Paper EOB

To receive a paper EOB, select the Request Paper EOB check box in Administration>Financial>Insurance Codes>EMC.

Test Submission Indicator

Select the Test Submission Indicator check box in Administration>Financial>Insurance Codes>EMC to indicate if this is a test file being sent.