Blue Review
A newsletter for contracting institutional and professional providers

February 2019

Illinois Medicaid: Encounter Compliant Claim Submission Requirements and BCBSIL Edits

In order to help supply complete and accurate data to the Illinois Department of Healthcare and Family Services (HFS), Blue Cross and Blue Shield of Illinois (BCBSIL) is implementing compliance edits for Blue Cross Community Health PlansSM (BCCHPSM) claims. BCBSIL has had a version of these edits in place since August 2016 for BCCHP claims. This article serves as notice that we are updating and aligning our existing edits with posted HFS standards.

In particular, please note that there is now formal guidance governing the allowable Place of Service (POS) codes that can be used for professional electronic (837P) and paper (CMS-1500) claims. The POS edit will represent new edits that BCBSIL has not applied previously to BCCHP claims. To view relevant documentation, refer to the Appendix A: Encounter Claims Crosswalks, posted recently on the HFS website.

These edits will read the provider data present on each submitted claim and compare it to the most recent provider extract file received from HFS. The provider extract file represents a complete listing of all HFS Medicaid registered providers and includes all current information on the Provider Type (PT) and Category of Service (COS) for each registered provider. It is supplied to BCBSIL from HFS weekly.

Using the data submitted on the claim, BCBSIL matches to any corresponding record within the provider extract file. The data identified via this match is then combined with the submitted data and compared to the relevant crosswalk row to validate whether the claim represents a compliant combination. An appropriate taxonomy code must be submitted on IL Medicaid claims, and is an integral component of the process. An example follows.

Example:

  1. An electronic professional claim (837P transaction) is submitted to BCBSIL for an office visit for a BCCHP member. The physician rendering the service bills their provider data in the following fields:
    • Rendering NPI Location: 2310B/NM109
    • Rendering Taxonomy Code Location: 2310B-PRV03 and/or 2420A-PRV03
  2. Using the submitted rendering NPI, BCBSIL matches it to the provider extract file. We find the provider is registered with provider type 10 and COS 1.
  3. We then compare the submitted data, taxonomy code and claim type, against the crosswalk, and we see that there is a valid combination for professional claims.

    4. PT

    COS

    Taxonomy Code

    10

    1

    207Q00000X
  4.  The claim is accepted for processing.

Note: If the check described in the example above is not passed, then the claim will reject with reason codes STC01-01 = A7 and STC01-02 = 107. A7 is Acknowledgement/Rejected for Invalid Information - The claim/encounter has invalid information as specified in the Status details and has been rejected; and 107 is Processed according to contract provisions (Contract refers to provisions that exist between the Health Plan and a Provider of Health Care Services).

If you have any questions, please contact your assigned Provider Network Consultant.