1. Inpatient and outpatient services must be billed (electronically or via hard copy) to First Priority Health (FPH) using either the HCFA -1450 billing format or the NUCC-1500 form and the appropriate revenue, ICD-9 and HCPC/CPT-4 codes. The member is held harmless except for non-covered services, designated copayments, deductibles, co-insurances, etc., or when instructed in writing by FPH.
   
   
2. Synertech, an imaging service, is handling all hard copy claims that are submitted to FPH.

First Priority Health
P.O. Box 69699
Harrisburg, PA 17106-9699

• Use red NUCC 1500 forms.
• Use HCFA 1450/UB92 forms.
• Bar-coded forms are not required as stated in the past, but can still be used if you have a supply.
• If it is necessary to use a highlighter, use only yellow or circle important data with black or
  blue ink.
• Use solid line printing rather than dot matrix printing.
• Use only black or blue ink for preparing handwritten claim forms.
• When it is necessary to submit a copy of a claim for processing, ensure that the copied claim is legible and dark enough to read.
• Do no use red ink.
• Do not submit carbon copies or microcopies of a claim for imaging.

3. All providers are required to submit claims within the time frames established.

• Claims must be received by FPH within one year of the date of service and/or discharge date or as contractually stipulated, based on the received date of the claim.
• In absence of any contract provision, claims must be received by FPH within one (1) year of date of service.
• If a claim is received with dates of service beyond the timely filing limitation, the dates of service will be denied and the submitting party will be responsible for the charges.
• Please allow 45 days for processing before resubmission.

4. In the event that the hospital does not have a prior authorization, the bill should still be sent to FPH. The provider will be notified by FPH on a remittance advice of the rejection of payment if the authorization is not on record and whether or not the member is responsible for the charges.
   
   
5. FPH participates in Point-of-Service (POS) programs which gives members more flexibility in choosing services. In some cases, the member may be responsible for obtaining prior authorization when necessary.
   
   
6. Pre-admission Testing (PAT) - Luzerne County has an outpatient radiology program (excluding Berwick & Hazleton), however, the radiology portion of pre-admission testing (chest X-rays) is excluded. The X-rays are billed by the facility performing the tests using procedure codes 71010 or 71020 with the appropriate primary diagnosis codes of V72.81, V72.82, V72.83, or V72.84.

Lackawanna and Luzerne Counties also have an outpatient lab program. All lab for pre-admission testing must be coordinated through the member’s Primary Care Physician, located in Luzerne or Lackawanna, whenever possible. Members must go to their PCPs’ office for blood draws if their PCP office provides that service. If a member’s PCP does not perform blood draws, the member must go to one of Pennant Lab’s designated blood drawing stations.

All other counties do not have an outpatient radiology or laboratory program, therefore, all pre-admission testing can be provided at any FPH participating facility.

Pre-admission testing is covered under the inpatient or SPU prior authorization regardless of date performed.

Please note:

• Pre-admission testing is covered even if the procedure is cancelled.
• A script is required for all testing.
• Pre-admission testing does not have to be provided at the same facility as the surgery
  as long as it is a participating FPH facility.
• Outpatient surgery may require prior authorization; please refer to your Provider Bulletin
  for further details.

7. Mother/Baby Claims – FPH requires both mother and baby charges be included on the same UB92 claim form. If your billing system cannot produce one claim for the mother/baby, two (2) separate claims may be submitted to FPH; however, these claims must be received together in order to ensure proper payment. (Exception is Point of Service Accounts).
   
   
8. Detained Baby Claims – Pre-certification is required in all cases when the baby is detained after the mother is discharged. Therefore, charges incurred for these admissions are to be handled separately from the original mother/baby claim that was submitted for the delivery. The services billed will be for the detained stay only.
   
   
9. Maternity Home Health Visit – When billing the mandated early discharge home health visit, use revenue code 551 and diagnosis code V24.2. A copayment does not apply to this service.
   
   
10. Bill Types (Outpatient vs. Short Stay/SPU) – All outpatient claims are to be submitted using the correct bill type in Locator 4 of the UB-92 claim form that corresponds to the services being billed.
    
    
11. Diagnostic/Screening Mammography – Submit claims for a diagnostic mammography with revenue code 401. Submit claims for a screening mammography with revenue code 403. The appropriate HCPC’s code must be billed to identify the nature of the test.
    
    
12. Itemization of Service – When billing for multiple dates of service on one claim (i.e. physical therapy, speech therapy, occupational therapy), please list each date of service in Locator 45 of the UB-92 claim form and the charge associated with the date in Locator 47.
    
    
13. Units – The field or locator must contain a numerical value of one (1) or higher; zeros will not be accepted. For providers who bill electronically, an edit will be placed in the system to require a numerical value in the units field or locator, therefore, you will receive an error if this information is not entered up-front.
    
    
14. Re-admission

Inpatient and outpatient claims will be examined for re-admissions and clinical correlation.

Claims will be combined based on a leave of absence when a re-admission is expected following an initial discharge, indicating the need for further medical/surgical treatment. Examples include, but are not limited to:

• situations when surgery could not be scheduled immediately;
• a specific surgical team is unavailable;
• bilateral surgery was planned; or
• treatment cannot begin immediately.

Placing the patient on a leave of absence will not generate two (2) payments. Only one bill and one payment will be made.

Re-admissions within 30 days of a preceding discharge will be reviewed to determine medical appropriateness of the initial discharge. If the initial discharge is determined to be premature, payment will be adjusted to reflect one episode of care.

15. Utilization

Claims will be reviewed to substantiate accuracy of billing and payment.

Claims will be reviewed to verify accuracy and completeness of pre-admission certification information. If inaccuracies exist based on actual medical record documentation, payment may be adjusted.

Cases in which a member is admitted and discharged the same day following a procedure will be reviewed for appropriateness of setting/accuracy of billing. Payment may be adjusted.

Cases in which a member is transferred to and/or from their acute care or psychiatric areas in the same episode of care will be combined and reimbursed under one DRG payment.

16. Delay/Cancellation Policy/Against Medical Advice (AMA)

If a BlueCare HMO member requests a delay or cancellation of an inpatient stay after the member has received some services, and the stay was considered medically necessary, the services which would have been covered on an outpatient basis, should be billed as an outpatient claim. Room and board charges are the member’s responsibility.

17. Postponement Policy

If the provider must postpone a procedure or test and the member must be re-admitted, one bill should be submitted that encompasses both admissions.

18. Payment Liabilities

Any charge not covered under the member’s First Priority Health agreement becomes the member’s responsibility.

Any charge rejected due to denial on the basis of medical necessity may become the member’s responsibility.

Any charge rejected due to benefit eligibility becomes the member’s responsibility.

Such charges include, but are not limited to:

1. durable medical equipment;
2. private room differential;
3. take-home drugs;
4. educational training;
5. deductibles; or
6. co-insurance and co-payments.

19. Refer to the Blue Cross of Northeastern Pennsylvania & First Priority Health Billing Manual for additional billing information regarding the HCFA 1450 (UB92) and the NUCC 1500,

First Priority Health responded to the challenge to simplify and expedite administrative processes by offering providers in our network the web-based system NaviNet^sm. This system allows providers to electronically link to FPH for a variety of purposes, including but not limited to:

• Member eligibility/copayments
• Service authorizations
• Claims submission/inquiry
• Electronic bulletin board (Blue Alert)
• BCNEPA Provider Center

• E* Services has been working diligently with several clearinghouses to accept claims electronically. Depending upon what electronic clearinghouse your billing program/service uses, a single data entry may be all that is required.
• If you currently do not have a method for electronic claims submission, FPH offers online claims entry via NaviNet^sm.

For detailed information or connection to any of the above capabilities, call the Provider Services Unit at 1-800-822-8752.

Under the terms of Act 68, Pennsylvania’s managed care bill, insurers have 45 calendar days from receipt to pay a clean claim submitted for reimbursement. A clean claim is defined by the Act as "a claim for payment for a health care service which has no defect of impropriety. A defect or impropriety shall include lack of required substantiating documentation or a particular circumstance requiring special treatment which prevents timely payment from being made on the claim." If the clean claim is not paid by the 45^th day, interest must be paid to the remitter of the claim. The interest is calculated beginning the day after the required payment date and ends on the date the claim is paid.

FPH will mail the check and a detailed claim listing, which indicates the claims for which you are receiving interest.

First Priority Health (FPH) allows providers to adjust previously submitted claims through the use of the FPH and Blue Cross of Northeastern Pennsylvania Adjustment form. Previously, two forms existed. The forms were combined to include both lines of business onto one form (Refer to Section K – "Forms"). Therefore, it is imperative when submitting the form that you indicate at the top whether or not it is a Blue Cross or FPH adjustment.

The combined adjustment form must be utilized by participating providers when attempting to:

• Add or delete a charge to a revenue code previously billed.
• Add or delete a diagnosis code, procedure code, etc.
• Cancel a previously submitted claim.
• Notify FPH that a previously billed claim should have been submitted as secondary to another insurer.

If you are submitting a late charge bill, please utilize the correct third (3^rd) digit bill type frequency of "5" (i.e. 135 for outpatient). Late charges should only be submitted when adding a charge on a revenue code that has not previously been billed.

Adjustment forms should be submitted to the following address or fax:

MANDATORY CLAIMS RESEARCH REQUEST FORM – NUCC 1500

FPH requires all providers to utilize the Mandatory Claims Research Request Form when research is requested on your own claims. A copy of a NUCC 1500 or the remittance advice must be attached. Please be sure that all necessary information is completed to ensure timeliness in researching your request.

Mail all requests to:

First Priority Health
Attention: Claims Research Department
19 North Main Street
Wilkes-Barre, PA 18711-0302

Claim inquiries can also be made 30 days after the submission date by contacting the Provider Services Unit at 1-800-822-8752, Monday through Friday, 8:00 a.m. to 5:30 p.m.

This form must be used or all documentation received will be returned. Please see Section K – "Forms" for a copy of the Mandatory Claims Research Request Form.

The following information is intended to serve only as general information and to assist you in identifying various situations when you should contact all insurers involved to actually determine the rule in effect.

Coordination of Benefits (COB) provisions were developed primarily to help eliminate duplication of medical payments. COB determines which insurer pays first when a member is covered under two or more health care plans. COB outlines what benefits available under the member’s FPH plan will be coordinated with benefits available under any other insurance coverage such as a secondary health insurance, automobile insurance, Worker’s Compensation, school insurance, or Medicare.

Our member’s Contract outlines that even when FPH is the secondary insurance, all services must be authorized by the PCP before they are rendered. Therefore, when your office is contacted for authorization, the appropriate pre-authorization should be given if the services are medically necessary and appropriate.

FPH will perform a thorough review of the responsibilities on the part of the identified primary payer and pay claims as a secondary insurance ONLY when proper authorization exists.

The primary plan, or the plan determined to pay first, must provide benefits up to the limitations of its contract as if no other insurance coverage existed.

If FPH is the secondary payer, FPH will pay for Member liability amounts for services rendered up to the limitations of the FPH contract.

Our member’s Contract outlines that even when FPH is the secondary insurance, all services must be authorized by the PCP before they are rendered. Therefore, when your office is contacted for authorization, the appropriate pre-authorization should be given if the services are medically necessary and appropriate.

If FPH’s internal COB files indicate that another insurance carrier is primary and FPH is the secondary carrier, FPH will require an Explanation of Benefit (EOB) form from the primary carrier before the claim will be considered for payment. If the EOB form from the primary insurance carrier is not submitted with the claim, the claim will be denied as FPH non-primary payer in need of an EOB from the primary insurance carrier.

• If you bill hard copy, please attach the primary carrier’s EOB to the claim.
• If you bill electronically, you can fax the primary carrier’s EOB to: FPH COB DEPT at (570)-200-6820 or mail the primary carrier’s EOB to "FPH COB Dept., 19 North Main Street, Wilkes-Barre, PA 18711".

First Priority Health coordinates with non-group policies.

Using the same logic stated above, employees who are:

• disabled (not working);
• covered by Medicare;
• do not have COBRA; or
• listed as active by an employer group with more than 100 total employees, are now inactive for primary/secondary COB determinations. This change will shift a larger burden to Medicare as it is primary over group plans for inactive employees. Medicare has always been primary for inactive employees employed by groups with less than 100 total employees.

The health insurance plan that has no COB provision pays before a plan that has a COB provision. The non-COB plan shall be considered the primary payer.

At times a person may be covered as an employee on two separate health plans, i.e. working two jobs. In that case, the plan covering the person longer pays benefits first, including any claims for covered dependents.

The benefits of the plan that covers the individual as an employee or member (other than as a dependent) are determined before those of the plan that covers the individual as a dependent.

If a person has coverage under one plan as a laid-off or retired employee, and under another plan as an active employee, the benefits provided by the plan which covers the individual as an active employee are determined before those of the plan which covers the individual as a laid-off or retired employee. The same rule applies to dependents covered under both policies.

For example:

• An individual is covered as a retiree under his former employer’s plan and is also covered as an active employee by his current employer. The plan that covers the individual as an active employee pays first.
• The same individual has family medical coverage for his dependent children. The active plan would pay primary for the children and the retiree plan would be secondary.

For determining the benefits for a retiree who is also covered as a dependent of an active employee, the plan that covers the person as a non-dependent (for example, as a retiree) pays before the plan that covers the person as a dependent.

For example:

• Assume that an individual has retiree medical coverage from his former employer and is also covered under his wife’s employer’s plan as her spouse. In this instance, the retiree plan pays first.

However, the above rules do not apply if the retiree is also a Medicare beneficiary. See the Medicare section below for further guidance.

First Priority Health determines the order of benefit payment for a dependent child by use of the "birthday rule" developed under the guidance of the National Association of Insurance Commissioners (NAIC). The primary coverage for a dependent child is the coverage of the natural parent as an employee whose birthday (month and day, not year) falls earlier in the year. For example, the coverage for a parent born on June 6 would pay benefits for a child before the coverage of a parent born September 2. If both natural parents have the same birthday, the plan that has been covering the parent longer pays first.

Since the birthday rule has not been mandated in all states, there may be some insurance carriers that still follow the male/female (gender) rule. If one coordinating plan uses the birthday rule and the other uses the male/female (gender) rule, both plans will follow the latter.

When parents are separated/divorced, neither the male/female (gender) or birthday rule applies, except in the case of custody.

For children of divorced/separated parents, the order of payers will be as follows:

1. The health care coverage of the natural parent with custody, as a policy holder, pays first;
2. The health care coverage of the spouse of the parent with custody, as a policyholder, (step-parent) pays second.
3. The health care coverage of the natural parent without custody, as a policyholder, pays last.

If there is a court decree that states that one of the natural parents is responsible for the child’s health care expenses, that plan pays first. The plan of the other natural parent shall be the secondary plan.

Newborn children of a policyholder or covered dependent (male or female) are covered for the first 31 days immediately following birth. Coverage after 31 days is contingent upon the policyholder enrolling the newborn child as a dependent within the 31-day period.

If both parents have health insurance, the birthday rule is followed to determine the primary and secondary payers.

Medicaid is always the secondary payer (except for members of the Children’s Health Insurance Program), no matter who carries it. It is possible for someone to have FPH through an employer and also have Medicaid. Providers can bill Medicaid after payment is received from FPH, but Medicaid will only pay up to the amount it normally pays. In most instances, FPH will have paid more than Medicaid would pay, therefore, billing Medicaid for any balance will usually not result in any payment. Providers cannot bill a member for any balance after Medicaid pays its usual fee. He/she would have to accept any payment from Medicaid as payment in full. As far as a Specialist is concerned, the member is only responsible for the co-payment he/she has for Medicaid.

CHAMPUS is health insurance given to active and retired service individuals. Not all service-related individuals have it. However, CHAMPUS is always the last payer (the only exception is that CHAMPUS remains primary payer to Medicaid).

Automobile insurance, as required by the Pennsylvania Motor Vehicle Financial Responsibility Act, is primary over FPH coverage. Pennsylvania law does not require coverage for motorcycles, snowmobiles or ATVs. However, if a Member chooses to purchase an optional medical coverage policy for their motorcycle, snowmobile or ATV, FPH will consider that medical coverage policy primary over
FPH coverage.

If a FPH member is injured in a motor vehicle accident, or sustains injury due to maintenance or use of a motor vehicle, it is the member’s automobile insurance that is the primary payer. FPH requires a letter of exhaustion from the applicable auto insurance carrier indicating that the Member has exhausted the First Party Benefits along with a copy of the payout sheet indicating the claims that were paid.

What if a Member doesn’t have auto insurance or doesn’t own a motor vehicle? If a member doesn’t have auto insurance, First Priority Health is not automatically primary for claims paid. Under Pennsylvania law, the following is the order or benefit determination that must be followed if the member does not own a currently registered vehicle or doesn’t possess auto insurance:

• Resident Relative: any active automobile insurance of a relative residing within the
  Member’s household.
• If the Member does not have auto insurance or does not have a resident relative with auto insurance, a notarized affidavit of NO AUTOMOBILE INSURANCE must state that the Member is/is not the owner of a currently registered vehicle and does not have active automobile insurance either through himself/herself or through resident relatives within his/her household
  on the date of the motor vehicle accident and must also provide FPH with a copy of the
  police report.
• Auto insurance of the vehicle the Member was driving, a passenger in, or hit by at the time
  of the accident.
• Auto insurance from any other motor vehicle involved in the accident.

If the Member was involved in a "Hit and Run" accident and does not possess auto insurance or
does not have a resident relative with auto insurance, FPH requires the appropriate notarized affidavit
of NO AUTOMOBILE INSURANCE and a copy of the police report indicating it was a "Hit and
Run" accident.

If no automobile insurance carrier is applicable, FPH will coordinate benefits with other applicable health insurance carriers.

NOTE: All notarized affidavits of NO AUTOMOBILE INSURANCE must be forwarded to FPH’s Other Party Liability Department.

Whenever an FPH member is injured, contracts a disease on the employer’s property, or during any company-sponsored sports events or activities, medical claims incurred as a result of that accident are the responsibility of the employer’s Worker’s Compensation carrier. Worker’s Compensation is always considered the primary carrier. FPH will review any claim previously denied as work-related upon receipt of a valid worker’s compensation denial from the Worker’s Compensation carrier.

FPH has the right to subrogate on claims paid on our members’ behalf if a member is pursuing a possible lawsuit or appealing a denial from another third party insurance.

When a child attends school, he/she is frequently covered by a small health or accident policy through the school. This policy is for use in case of accidents occurring at school or in school-related activities. Most policies state in the contract that they are "Supplemental Only" or there is a "No Coordination of Benefits" clause, in which case they would be in the last payer position.

According to the Unfair Insurance Practice Act, FPH is required to provide all providers a list of claims that have not completed processing within a specific time frame. The claim information is reported on the Patient List/Delayed Claims.

Based on the date the claim was received by FPH, listings are made available on the following days:

• 12 days, 19 days, 30 days and every 45 days thereafter.

All claims payments, denials and adjustments will be documented on a Remittance Advice (RA). You should retain this information for your records. RAs are now sorted alphabetically by the member’s last name.

First Priority Health (FPH) is part of the national BlueCard Program. With BlueCard, members have a simple, direct way to receive out-of-area care through a large network of providers ¾ 85% of physicians and hospitals across the country contract with Blue Cross and Blue Shield Plans as well as some international providers.

When traveling in another Plan’s service area, FPH members receive the same benefits and pay the same copayments as they do with their First Priority Health coverage, and they have access to participating BlueCard providers through a single 800-phone number (1-800-810-BLUE) as well as a web site address (www.BCBS.com).

The three-digit alpha code (YZH) and the "suitcase" graphic on the FPH membership identification card is used by out-of-area providers to identify First Priority Health as part of the BlueCard Program. The code and the suitcase let providers know that the patient is a BlueCard member and give providers the ability to process the member’s out-of-area claims. Out-of-area BlueCard members will have a different three-digit alpha prefix on their identification cards.

Urgent care is defined as care for an unexpected illness or injury that is not life-threatening, but cannot be reasonably postponed until the member returns home, (fever, flu, etc). When BlueCard members obtain services from your facility, they are responsible for the appropriate copayment as indicated on their identification card.

Claims are submitted (electronically or via hard copy) to your local Blue Cross (BCNEPA). Remember to include the three-digit alpha prefix for out-of-area BlueCard members. Hard copy claims are to be submitted to:

BCNEPA
Blue Cross Claims Department
19 North Main Street
Wilkes-Barre, PA 18711-0302

Referred care is defined as follow-up medical care necessary to treat an illness or injury that originated at home (allergy shots, removal of stitches, etc.). Upon appointment, out-of-area members will present a Transfer of Medical Information Form (TMIF), which allows the transfer of necessary medical information. See Section K, "Forms". Upon rendering services, complete the TMIF and mail or fax to the member’s physician noted on the form. BlueCard members are responsible for the appropriate copayment as indicated on their identification card. Claims are to be submitted as noted above in the Urgent Care section.

Emergency care does not change under the BlueCard Program. If a situation arises that the member requires emergency services, treatment is to be sought from the nearest facility. Copayments may be collected at the time of service. Claims are submitted as noted above.

Effective August 1, 2001, some of our POS accounts have transferred to BlueCard Managed Care/POS accounts. The BlueCard Managed Care/POS program is for members who reside outside their BCBS Plan’s service area. However, unlike other BlueCard programs, First Priority Health BlueCard Managed Care/POS members are actually enrolled in the FPH network and Primary Care Physician panels. Therefore, you should treat these members as you treat any other FPH POS member, applying the same referral practices and network protocols.