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. For other language assistance or translation services, please call the customer service number for . Usually, Providers file claims with us on your behalf. Or, you can call the number listed on the back of your Regence BlueCross BlueShield of Oregon identification card. Learn more about when, and how, to submit claim attachments. Prescription drug formulary exception process. Filing tips for . Blue Shield (BCBS) members utilizing claim forms as set forth in The Billing and Reimbursement section of this manual. Emergency services do not require a prior authorization. Services provided by out-of-network providers. The main pages include original claims followed by adjusted claims that do not have an amount to be recovered. Please have the following information ready when calling to request a prior authorization: We recommend you work with your provider to submit prior authorization requests. 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. 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. No enrollment needed, submitters will receive this transaction automatically. 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. If you pay all outstanding premiums before the date specified in the notice of delinquency, Providence will reinstate your coverage and reprocess your prescription drug claims applying the applicable cost-share. and part of a family of regional health plans founded more than 100 years ago. Appeal: 60 days from previous decision. We may not pay for the extra day. Your Deductible is the dollar amount shown in the Benefit Summary that you are responsible to pay every Calendar Year for Covered Services before benefits are provided by us. We recommend you consult your provider when interpreting the detailed prior authorization list. If an Out-of-Network Provider charges more than your plan allows, that Provider may bill you directly for the additional amount. For the Health of America. Coronary Artery Disease. The Centers for Medicare & Medicaid Services values your feedback and will use it to continue to improve the quality of the Medicare program. Waiting too long on the phone, waiting room, in the exam room or when getting a prescription, The length of time required to fill a prescription or the accuracy of filling a prescription, Access to health care benefits, including a pre-authorization request denial, Claims payment, handling or reimbursement for health care services, A person who has bought insurance for themselves (also called a contract holder) and any dependents they choose to enroll. The member can appeal, or a representative the member chooses, including an attorney or, in some cases, a doctor. 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. (b) Denies payment of the claim, the agency requires the provider to meet the three hundred sixty-five-day requirement for timely initial claims as described in subsection (3) of this section. Para humingi ng tulong sa Tagalog, pakitawagan ang numero ng telepono ng Serbisyo sa Kostumer (Customer Service) na nakasulat sa likod ng inyong kard bilang miyembro. We're here to supply you with the support you need to provide for our members. Your Coinsurance for a Covered Service is shown in the Benefit Summary, and is a percentage of the charges for the Covered Service. Learn about electronic funds transfer, remittance advice and claim attachments. Were here to give you the support and resources you need. A single payment may be generated to clinics with separate remittance advices for each provider within the practice. What kind of cases do personal injury lawyers handle? 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. We will notify you once your application has been approved or if additional information is needed. Fax: 877-239-3390 (Claims and Customer Service) If the first submission was after the filing limit, adjust the balance as per client instructions. Provider temporarily relocates to Yuma, Arizona. PO Box 33932. Regence BlueShield. Coverage decisionsA coverage decision is a decision we make about what well cover or the amount well pay for your medical services or prescription drugs. BCBS Prefix List 2021 - Alpha. Telehealth services are provided to member, claim is submitted to Blue Cross of Idaho. When purchasing a Prescription Drug, you may have to pay Coinsurance or make a Copayment. You can make this request by either calling customer service or by writing the medical management team. View sample member ID cards. Stay up to date on what's happening from Seattle to Stevenson. Services not covered because Prior Authorization was not obtained; Services in excess of any maximum benefit limit; Fees in excess of the Usual, Customary and Reasonable (UCR) charges; and. 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. Including only "baby girl" or "baby boy" can delay claims processing. Claims with incorrect or missing prefixes and member numbers . Providence has the right, upon demand, to recover from a recipient the value of any benefit or Claim payment that exceeded the benefits available under your Contract. You can use Availity to submit and check the status of all your claims and much more. BlueCross BlueShield of Oregon, Regence BlueCross BlueShield of Utah, and Regence BlueShield (in . 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. If additional information is needed to process the request, Providence will notify you and your provider. You stay an extra day in the hospital only because the relative who will help you during recovery cant pick you up until the next morning. If you are in a situation where benefits need to be coordinated, please contact your customer service representative at800-878-4445 to ensure your Claims are paid appropriately. We reserve the right to suspend Claims processing for members who have not paid their Premiums. Your coverage will end as of the last day of the first month of the three month grace period. We respond to pharmacy requests within 72 hours for standard requests and 24 hours for expedited requests. 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. This is not a complete list. 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. RGA employer group's pre-authorization requirements differ from Regence's requirements. 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. We will notify you again within 45 days if additional time is needed. Provided to you while you are a Member and eligible for the Service under your Contract. Visit HealthCare.gov to determine if you are eligible for the Advance Premium Tax Credit. You can submit feedback about your Medicare health plan or prescription drug plan directly to Medicare. State Lookup. Usually we will send you an Explanation of Benefits (EOB) statement or a letter explaining our decision about a pre-authorization request. Consult your member materials for details regarding your out-of-network benefits. Failure to obtain prior authorization (PA). During the first month of the grace period, your prescription drug claims will be covered according to your prescription drug benefits. Please note: Capitalized words are defined in the Glossary at the bottom of the page. MAXIMUS Federal Services is a contracted provider hired by the Center for Medicare and Medicaid Services (also known as CMS) and has no affiliation with us. regence.com. Contact Availity. 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. The Blue Cross and/or Blue Shield Plans comprising The Regence Group serve Idaho, Oregon, Utah and much of Washington state

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