Unit 2: Electronic Claim Submission

6.2 Benefits of Electronic Claim Submission

6.2 Highmark EDI Services Support

6.2 Required Electronic Claim Submission Formats

6.2 Submitting Claims (NY Only)

6.2 Real-Time Estimation and Adjudication

6.2 Claims Record Management

6.2 Attachments for Electronic Claims

6.2 NAIC Codes

6.2 Claim Status Inquiries

6.2 Availity 1500 and UB Claim Submission

6.2 Disclaimers

6.2 Benefits of Electronic Claim Submission

All it takes is a computer, the proper software, and an Internet connection for electronic claims submission. Instead of printing, bundling, and sending paper claims through the mail, simply enter and store claims data through your office computer.

Faster Claim Payment

Electronic claims are convenient, confidential, and operational around the clock. Highmark’s claim processing system places a higher priority on claims filed electronically. Electronic claims will typically process in seven to 14 calendar days, whereas paper claims will process in 21 to 27 calendar days.

Regulatory Compliance

The payment progress targets defined above that are used in Pennsylvania are in compliance with timely claims payment regulations defined by Pennsylvania’s Act 68, and reflect processing of clean claims that do not require manual intervention or investigation.

The payment progress targets defined above that are used in Delaware are in compliance with timely claims payment regulations defined by Delaware Insurance Regulation 1310, and reflect processing of clean claims that do not require investigation.

In West Virginia, the payment progress targets defined above are used and are in compliance with the timely claims payment regulations defined by the Ethics and Fairness In Insurer Business Practices Act, W.Va. Code §33-45-1 et seq., commonly referred to as the “Prompt Pay Act”, and reflect processing of clean claims that do not require investigation.

For more information on these regulations, please see the manual’s Chapter 6.1: General Claim Submission Guidelines.

Cost Effective

Electronic claim submission increases staff productivity by speeding claim preparation and delivery. Many of the paper claim processes are eliminated such as form printing, bundling, postage, and mailing.

Many errors experienced in the keying and processing of paper claim forms are reduced or eliminated. Electronic claim submission means greater claim acceptance rates and reduced staff time in claim research and resubmissions. 

Convenient and Confidential

Electronic submission provides the added benefit of both claim preparation and delivery at your convenience. Postal service hours of operation or delays do not limit your productivity. Electronic claims can be submitted 24 hours a day, seven days a week, 365 days a year. It is safe, immediate, and direct to Highmark. EDI security standards are in place to ensure your claim data remains confidential and secure.

HIPAA-compliant 1500 (837P) and UB (837I) claim submission transactions are available to participating professional providers and facilities in Availity.

For More Information

For information on signing up for EDI and also Availity, please see the manual’s Chapter 1.3: Electronic Solutions – EDI & Availity.

To learn more about electronic claims submission, visit the Electronic Data Interchange (EDI) Services website. You can access the site by selecting Claims & Authorization then Reimbursement Resources from the main menu on the Provider Resource Center, or by clicking the applicable link below to access the site directly:

• Pennsylvania: highmark.com/edi
  
• Delaware: highmark.com/bcbsde
• West Virginia: highmark.com/edi-wv
• New York: https://www.ask-edi.com/

6.2 Highmark EDI Services Support

The Highmark EDI Operations support staff is comprised of trained personnel dedicated to supporting electronic communications. They provide information and assistance with questions or problems you encounter with any aspect of your EDI transactions.

Support is free and staff is available Monday through Friday from 8 a.m. to 5 p.m. To save time when calling, be prepared to provide your Trading Partner number, NPI, and log-on identification to the support analyst.

EDI Phone Contact

Delaware, Pennsylvania, and West Virginia:

To contact a support analyst by phone, call 800-992-0246.

New York: For support, call Administrative Services of Kansas at 800-472-6481.

Accessible 24 Hours a Day, 7 Days a Week

Electronic transactions can be sent and retrieved seven days a week, 24 hours a day. Electronic transactions can be submitted once or multiple times per day or week. Claim transmittal and report retrieval schedules are controlled by each office.

Information on EDI Claim Submission can be found on the EDI website by visiting the Electronic Data Interchange (EDI) Services website via the Provider Resource Center, or by clicking the applicable link below to access the site directly:

• Pennsylvania: highmark.com/edi
• Delaware: highmark.com/bcbsde
• West Virginia: highmark.com/edi-wv
• New York: https://www.ask-edi.com/

The EDI website has the most up-to-date information about doing business electronically with Highmark. Highmark recommends that you bookmark this site and consider it your first source when you have a problem or question.

6.2 Required Electronic Claim Submission Formats

In 1979, the American National Standards Institute (ANSI) chartered the Accredited Standards Committee (ASC) X12 to develop and maintain uniform standards for Electronic Data Interchange (EDI). ASC X12N is the section of ASC X12 for the health insurance industry’s administrative transactions.

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the Administrative Simplification provisions named ASC X12N as the mandated standard to be used for electronic transmission of health care transactions.

Required Claim Submission Format

The current HIPAA electronic transaction standards for health care eligibility, claim status, referrals, claims, and remittances are the ASC X12N Version 5010 transactions. The required formats for electronic claim submission are:

• Professional: ASC X12N 837 Health Care Claim: Professional Transaction Version 005010 (“837P”)
• Institutional: ASC X12N837 Health Care Claim: Institutional Transaction Version 005010 (“837I”)

The following types of electronic claim submission are available to participating facilities:

• Batch submission and Real-Time Estimation/Adjudication (limited to a single claim) via any electronic data interchange vendor
• Availity^® Facility Claim

Professional providers have the following options:

• Submission via any electronic data interchange vendor or billing service
• Availity^® Professional Claim

Note: The Availity claim submission transactions are compliant with the HIPAA 837P and 837I formats.

6.2 Submitting Claims(NY Only)

Submitting Claims

To improve accuracy and timeliness of paper claim submissions, we utilize Optical Character Recognition/Intelligent Character Recognition (OCR/ICR). To maximize the efficiency of this technology, we are asking providers who submit paper claims to use the red CMS 1500 (2-12) or UB-04 standard claim forms.

NOTE: Edits for electronic claims and paper claims are exactly the same. Submitting a paper claim that originally rejected electronically without fixing the problem will only lead to a rejection of the paper claim as well.

All claims for Medicare-covered services and items that are the result of physician's order or referral shall include the ordering/referring physician's name, NPI, and taxonomy code in boxes 17, 17a, and 17b of the CMS 1500 claim form. The following services/situations require the submission of the referring/ordering provider information. This is not an all-inclusive list:

• Medicare-covered services and items that are the result of a physician's order or referral
• Parenteral and enteral nutrition
• Immunosuppressive drug claims
• Hepatitis B claims
• Diagnostic laboratory services
• Diagnostic radiology services
• Portable x-ray services
• Durable medical equipment

When the ordering physician is also the performing physician (as often is the case with in-office clinical laboratory tests)

Claim Submission Tips

• Use the red CMS 1500 or UB-04 claim forms.
• Check your printer to ensure that your ink is dark.
• Do not highlight data on the claim form.
• Check your printer to ensure that it is lined up with the fields on the claim form.
• If the information submitted is incorrect or missing, we may generate a letter asking you to resubmit the claim with the correct information.
• The use of any other type of CMS1500 or UB-04 claim forms other than the red forms will delay processing.
• Paper claims must have a physical address in box 33; if a PO Box is submitted, the claim will be returned for correction and resubmission.
• ZIP Codes must be submitted with 9 digits
• Include the referring/ordering physician NPI as required by CMS billing requirements. 

Submitting Appeals

Submit all timely filing appeal requests in writing, stating the reason for the delay of submission beyond 365 days. The claims you are appealing must be on paper and attached to your appeal. Please keep copies of the information you send for ease in identifying claims that will be approved/denied.

Electronically Submitted Claims:

For electronic claims that have not been processed, please submit one of the following reports with your appeal request and claim(s):

• Deleted Claim Edit Report
• Clearinghouse Response files

If you would prefer to receive these reports instead of your vendor, please contact ASK at 800-472-6481.

If you are using the electronic response file to do automatic posting of errors or claims accepted, the following information needs to be included on the report you send to us:

• Error record
• Record sequence
• Error code
• Clearinghouse messages
• Error field
• Error description

Continue to balance your submission counts to those on the Clearinghouse Response file. If a discrepancy exists between the counts, notify our Help Desk immediately. The Clearinghouse Response file will be the only notification you will receive about a claim deleted in the transmission.

If you currently do not receive any of the above reports or experience discrepancies on claim counts, contact ASK at 800-472-6481.

Clearinghouse Rejections

If a claim rejects in the clearinghouse (i.e., invalid member identification number), submit your deleted claim edit report and claim with your appeal. 

Coordination of Benefits

If an insurance carrier other than Highmark Blue Cross Blue Shield of Western New York or Highmark Blue Shield of Northeastern New York is the primary carrier, then providers must submit the other carrier's payment voucher and claim within three months of the payment from the other carrier. COB claims can be submitted using the 8371 or 837P. Providers do not need to submit the other carrier explanation of benefits (EOB) if all of the information is submitted on the 837.

If providers are receiving an 835 (electronic remittance), they may or may not have a paper voucher or EOB to submit to Highmark Blue Cross Blue Shield of Western New York or Highmark Blue Shield of Northeastern New York. The information received on the 835 should be incorporated into the secondary fields on the 837.

Incorrect Insurance Information

If the member provided incorrect insurance information, the denial notice from the other carrier must be submitted with the original claim within three months of the other carrier's denial.

No Coverage

If a participating provider, in dealing with a patient finds that he/she has no insurance, the member should be asked to sign and date a patient responsibility form or waiver.

A provider may seek payment from the patient for any services provided. If the member realizes that he or she has Highmark Blue Cross Blue Shield of Western New York or Highmark Blue Shield of Northeastern New York coverage after a provider has billed the member and the claim is beyond the 365-day timely filing limit, the provider should submit the signed waiver/patient responsibility form and claim with your appeal. Do not re-bill the member.

If you do not have a signed waiver, submit copies of billing statements with your claim(s) and appeal that indicates that you have billed the member who has now advised you that he/she has Highmark Blue Cross Blue Shield of Western New York or Highmark Blue Shield of Northeastern New York insurance.

Member Held Harmless

Participating providers are responsible to abide by the stipulations of the Highmark Blue Cross Blue Shield of Western New York or Highmark Blue Shield of Northeastern New York provider agreements. In cases where services were not billed to us within the timely filing limits, you cannot bill the member directly.

The member is to be held harmless. The reimbursement issue is between you as a participating provider and us as the insurer. You may file the claim late with a request to waive the limit with an explanation. Upon review of your appeal, approval or denial will be determined. However, at no time is the member to be held responsible.

Filing Requirements for Members and Non-Participating Providers

Claims submitted by members or non-participating providers (for traditional and approved services through our managed care contracts) must be submitted within the following time frames:

• Major Medical: 12 months
• Traditional: 12 months

If claims, requests for adjustments, appeals or claim reviews are submitted by the member or a non­ participating provider after the above time frames, the claim will be denied. The non-participating provider can bill the member for these denied claims.

New York State Prompt Pay Interest

Prompt Pay Interest exceeding $1.99 per claim is generated on a daily basis for claims not processed within 30 days of Blue Cross Blue Shield's receipt of the claim. Checks and wire payments are issued more frequently than the weekly cycle to ensure that prompt pay requirements are met. Any interest paid appears under the "Interest Paid" column on your payment voucher.

Claims submitted for adjustment due to errors caused by Blue Cross Blue Shield processing receive prompt pay interest.

The following are excluded from prompt pay interest:

• Administrative Services Only (ASO) & Administrative Services for National Accounts (NSO) contracts
• Federal Employee Plan (FEP) contracts
• Services rendered by out-of-state providers
• Senior Blue and BlueSaver claims from non-participating providers
• National Accounts, when an out-of-state Plan, is the control Plan
• Blue Card claims for Members from Plans outside New York State, home and host If you are a capitated provider billing for fee-for-service procedures, prompt pay interest will be calculated for those claims, if necessary.

Coordination of Benefits Payments

Coordination of benefits applies to members who have more than one group health insurance contract. Blue Cross Blue Shield coordinates benefit payments with other carriers to ensure members receive all of the benefits to which they are entitled and to prevent duplicate payments. Other insurance information should be verified each time that a patient visits your office.

Prior Authorization and Referral Requirements

For managed care (including POS in-network claims), all prior authorization/referral policies and procedures apply, even though Blue Cross Blue Shield may be the secondary payer.

For Preferred Provider Organization (PPO) contracts, all prior authorization policies and procedures apply, even though Blue Cross Blue Shield may be the secondary payer.

If appropriate prior authorization of services has not been made, or if a valid referral has not been issued before processing a claim, we may deny payment even on a secondary basis if the services are determined not to be medically necessary. 

Primacy

When a patient is covered by two or more health insurance plans, one plan is determined to be primary and its benefits are applied to the claim. The following rules apply when determining which carrier is primary:

1. If one policy does not have a COB provision, then it will be primary.
2. If the patient is covered under one policy as the employee and under another policy as a dependent, the policy which covers the patient as an employee will be primary.
3. The primary policy for children is the policy of the parent whose birthday (month and day) falls earlier in the year. If both parents have the same birthday, the policy that covered the parent longer is primary.
4. When there is more than one insurance policy and the parents are divorced or separated, the rules of primacy vary depending on the court decision.
5. If the patient is the policy holder and covered under one of the policies as an active employee, neither laid off nor retired, and also covered under another policy as a laid off or retired employee, the policy covering the patient as an active employee will be primary.
6. If none of the above applies, then the policy that has covered the patient for the longest time will be primary.

Submitting Claims for Secondary Reimbursement

Claims must be submitted electronically in the 837P or 8371 format, or on paper using a CMS 1500 or UB-04. All line items billed to the primary carrier should be submitted on the secondary claim.

Attach a copy of the primary carrier's Explanation of Benefits Statement and indicate balance due. The balance due is the amount to be considered by Blue Cross Blue Shield or the patient's responsibility.

Attach a copy of the primary carrier's Explanation of Benefits Statement. Claims submitted on paper without the Explanation of Benefits Statement, will be rejected.

PPO or  POS Claims

When a claim for Traditional, PPO or POS out-of-network services is secondary, our payment will not exceed our allowance for the services. Also, the sum of the primary and secondary payments will not exceed the provider's charge. 

Bill Your Usual Charge

Regardless of our allowance for a service, you should always bill your usual charge. This is beneficial in several ways:

1. It enables us to determine average charges for procedures.
2. By using one charge to bill all insurance companies, the chance of billing errors is reduced.
3. If more than one insurance company has liability for a claim, your standard charge eliminates confusion and helps to ensure proper payment.
4. Professional Courtesy – No reimbursement will be provided to a provider billing for professional services rendered to his/her immediate family, regardless of whether the family member has coverage under a Blue Cross Blue Shield contract. Immediate family is defined as the provider's spouse, children, parents, and siblings. Blue Cross Blue Shield will not reimburse for services that would normally have been furnished without charge.

6.2 Real-Time Estimation and Adjudication

Highmark’s Real-Time tools are available to all Availity-enabled contracted providers and to providers who submit electronic claims through a practice management system. These primary Real-Time capabilities include Real-Time Provider Estimation and Claims & Encounters.

These real-time capabilities give providers the ability to discuss member financial liability with patients when services are scheduled or provided. Providers could also collect applicable payment or make payment arrangements at the time of services, if they wish to do so.

Patient Cost Estimator

The Patient Cost Estimator tool gives providers the ability to submit requests for specific health care services before or at the time services are rendered and receive a current estimate of the member’s financial liability within seconds before the services are rendered.

The estimate takes into account the cost of the service provided and the amount of the deductible, coinsurance, and/or copayment and other coverage provisions included in the member’s benefit program. This information, in turn, can be utilized to set the member’s cost expectations prior to receiving services and collect or make arrangements for payment at the time of service.

This tool should be used to give members an accurate estimate of their financial obligations prior to or at the time of service. To determine member liability after services are rendered, it is recommended that providers use Claims & Encounters (see below).

In Availity, this tool can be accessed in Eligibility and Benefits Inquiry.

Note: Patient Cost Estimator can be used for all Highmark products; however, estimate submission is not available for the Federal Employee Program (FEP).

Claims & Encounters (Claim Submission)

Claims & Encounters in Availity gives providers the added ability to submit claims for specific health care services and receive a fully adjudicated response within seconds. This allows providers to determine, at the time of service, the correct amount the member owes. This, in turn, enables the provider to collect payment or make payment arrangements for the member’s share of the cost at the time of service.

Accelerated Provider Payment

Accelerated Provider Payment allows providers who meet certain criteria to receive accelerated payment on real-time submitted claims. Providers will receive more frequent payments from Highmark — within three business days for claims that have been submitted in real-time.

Note: Accelerated payment does not apply to amounts paid from the member’s consumer spending account.

Accelerated Member EOB on Member Portal

Accelerated Explanation of Benefit (EOB) displays the member explanation of benefits (EOB) on the Highmark Member portal the next business day for all real-time submitted claims.

Refunding the Member

These Real-Time Capabilities allow providers to get fast, current, and accurate information to help in determining the patient’s financial liability prior to or at the time of service. The provider tools will be especially useful as the member cost sharing increases and the use of spending accounts grow.

Please note, however, that if you collected payment from the member at the time of service for member liability, and then subsequently receive payment from Highmark and find an overpayment, be sure to issue the refund directly to the member within 30 calendar days.

Electronic Data Interchange (EDI) Services

Providers who are interested in integrating real-time capabilities within their practice management system should discuss this functionality with their software vendors. They should also review the Electronic Data Interchange (EDI) transaction and connectivity specifications in the Resources section on the EDI website.

To access the EDI website from the Provider Resource Center, select Claims & Authorization then Reimbursement Resources from the main menu, or click on the applicable link below to access the applicable site directly:

• Pennsylvania: highmark.com/edi
  
• Delaware: highmark.com/bcbsde
• West Virginia: highmark.com/edi-wv
• New York: https://www.ask-edi.com/

6.2 Claims Record Management

Highmark provides electronic acknowledgments to enhance your ability to track and monitor your claim transactions.

Acknowledgment Transactions

Electronic claims can be submitted via the 837 Professional (837P) and Institutional (837I) Health Care Claim Transactions. Upon receipt of the 837 transaction, there are several acknowledgment transactions available for tracking electronic claim submissions and payment depending on the capabilities of your software:

• 999 – Implementation Acknowledgment for Health Care Insurance
• 277CA – Claim Acknowledgement
• 835 – Electronic Remittance Advice ERA

Important!

Highmark Blue Cross Blue Shield of Western New York and Highmark Blue Shield of Northeastern New York providers will receive electronic claims information from Administrative Services of Kansas (ASK -EDI).

999 – Implementation Acknowledgment for Health Care Insurance

When transmitting claims in HIPAA Version 5010, you will receive the 005010X231 999 Transaction verifying that Highmark received your claim(s) file and indicating whether the file was “accepted” or “rejected” for further claim editing.

277CA – Health Care Claim Acknowledgment

This transaction is available approximately 24 hours after an accepted/accepted with errors 999 Implementation Acknowledgment for Health Care Insurance report is accepted. After the EDI claim editing process is complete, you are able to verify through the 277CA Claim Acknowledgment transaction that your claims were accepted and forwarded for claims processing. The 277CA also identifies claims that did not pass or were rejected by the editing process due to data errors.

The 277CA should be reviewed after every accepted/accepted with errors claim file transmission because it provides a valuable and detailed analysis of your claim file. Claims that were accepted should not be resubmitted. Highmark will no longer attempt to correct or retrieve missing information — this rejected claim data must be corrected and the claim resubmitted electronically.

Trading partners submitting 837 claim transactions in Version 5010 must be able to accept the 005010X214 277 Health Care Claim Acknowledgment (277CA) Transaction.

835 – Health Care Claim Payment/Advice(Electronic Remittance Advice- ERA)

The 835 Health Care Claim Payment Advice, or Electronic Remittance Advice (ERA), is essentially an electronic version of a paper Explanation of Benefits (EOB) or remittance. When 835 ERA information is combined with an Accounts Receivable System (ARS), it provides an efficient method of reconciling your patients’ accounts by providing financial information relating to your claim payments and denials. Your software vendor can advise you on your system’s ERA and ARS capabilities.

Highmark’s ERAs (835 transactions) are created on a weekly or daily basis to correspond with our weekly or daily payment cycles. Contact your software vendor to determine if your software is ERA capable. This transaction can help you reduce costs and improve office efficiency. Its benefits are:

• Eliminates posting errors: Little to no manual intervention, depending on the AR system, is necessary with electronic 835 posting. Errors associated with manual keying of payment data are eliminated.
• Reduces posting time: The 835 information allows you to electronically post payments to your AR system in a matter of minutes or hours instead of days. Actual posting time is dependent on the practice size and AR system. Electronic posting allows your staff more time to attend to patient needs instead of administrative tasks.
• Accelerates payment process: Electronic posting accelerates your ability to perform secondary billing of non-contractual financial liabilities. The Health Care Claim Payment/Advice (835) payment transaction files become available for retrieval after the payment cycle is complete, and remains available for seven days. You can start your posting and subsequent secondary billing processes upon receipt of the electronic file. 

For More Information

To learn more about claims record management transactions, please visit the Electronic Data Interchange (EDI) Services website via the Provider Resource Center (select Claims & Authorization then Reimbursement Resources from the main menu), or by clicking the applicable link below to access the site directly:

• Pennsylvania: highmark.com/edi
• Delaware: highmark.com/bcbsde
• West Virginia: highmark.com/edi-wv
• New York: https://www.ask-edi.com/

6.2 Attachments for Electronic Claims

Electronic Claim Attachments

It is not necessary or recommended that you submit claims requiring attachments via paper except in certain instances. These claims should be sent electronically utilizing the PWK, or paperwork attachment, specifications of the 837 electronic claim transaction. Two PWK option fields are built into the 837 transaction.

Supporting documentation can then be faxed or mailed to Highmark as indicated below for your service area:

PWK Cover Sheet

When submitting the additional documentation, please use the applicable cover sheet for your service area:

• Pennsylvania: PWK (Paperwork) Supplemental Claim Information Cover Sheet
• Delaware: PWK (Paperwork)Supplemental Claim Information Cover Sheet
• West Virginia: Electronic Claim Attachment Cover Sheet
• Western New York: Claim Attachment Cover Sheet
• Northeastern New York: Claim Attachment Cover Sheet

These cover sheets are also available on the Provider Resource Center. Select Resources & Education then Forms from the main menu, and then select Miscellaneous Forms.

Visit EDI Website for PWK Specifications

To review the specifications and PWK process flow, please visit the Resource Center, and then select Claims & Authorization then Reimbursement Resources from the main menu to access the Electronic Data Interchange (EDI) Services website(s).

If you currently work with a trading partner (software vendor and/or clearinghouse), or have an information technology (IT) department within your facility, they will be able to assist you with the technical aspects of the specifications. Simply tell your trading partner that you want to begin submitting attachment claims electronically.

6.2 NAIC Codes

The National Association of Insurance Commissioners (NAIC) is the U.S. standard-setting and regulatory support organization created and governed by the chief insurance regulators from the 50 states, the District of Columbia and five U.S. territories. Through the NAIC, state insurance regulators establish standards and best practices, conduct peer review, and coordinate their regulatory oversight. NAIC staff supports these efforts and represents the collective views of state regulators domestically and internationally. NAIC members, together with the central resources of the NAIC, form the national system of state-based insurance regulation in the U.S.

NAIC codes are unique identifiers assigned to individual insurance carriers. Accurate reporting of NAIC codes along with associated prefixes and suffixes to identify the appropriate payer and to control routing is critical for electronic claims submitted to Highmark EDI (Electronic Data Interchange).

Claims billed with the incorrect NAIC code will reject on your 277CA report as A3>116, “Claim submitted to the incorrect payer.” If this rejection is received, please file your claim electronically to the correct NAIC code. Please refer to the tables below for applicable NAIC codes for your service area.

Providers must submit claims through the Administrative Services of Kansas (ASK): www.ask-edi.com.

*Providers will continue to submit claims to Empire for Empire/Anthem members who are seen in — Albany, Clinton, Columbia, Essex, Fulton, Greene, Montgomery, Rensselaer, Saratoga, Schenectady, Schoharie, Warren, and Washington counties — that comprise the 13 counties of the Highmark Blue Shield of Northeastern New York service region.

*Providers will continue to submit claims to Excellus for Excellus members who are seen in — Clinton, Essex, Fulton, and Montgomery counties — that comprise four of the 13 counties of the Highmark Blue Shield of Northeastern New York service region.

Pennsylvania

West Virginia

6.2 Claim Status Inquiry

Highmark offers providers electronic means of checking the status of a claim through Availity^® Claim Status Inquiry or the HIPAA 276/277 Health Care Claim Status Request and Response transactions. For more information, reference the Highmark Provider Manual 6.1 Claim Status Inquiries.

6.2 Availity 1500 and UB Claim Submission

Availity^® claim submission transactions let you submit HIPAA-compliant 837P Professional claims and 837I Institutional claims fast and easy in real-time. Availity’s real-time, single claim-submission lets you know the status of a claim at the time of entry and claim errors are corrected online. When submitted on the date the services were rendered, these capabilities allow providers to accurately identify and collect member responsibility before the patient leaves the office.

Accessing Claim Submission Transactions

To access the claim submission transaction in Availity, go to Claims & Payments and then click on Claims & Encounters.

Availity^® Customer Support

If you need assistance with an existing account and cannot log in to submit a ticket, or have started the registration process and are experiencing issues, you can call 800-AVAILITY (282-4548). For more information about contacting Availity, click HERE.

6.2 Disclaimers

The following entities, which serve the noted regions, are independent licensees of the Blue Cross Blue Shield Association: Western and Northeastern PA: Highmark Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Choice Company, Highmark Health Insurance Company, Highmark Coverage Advantage Inc., Highmark Benefits Group Inc., First Priority Health, First Priority Life or Highmark Senior Health Company. Central and Southeastern PA: Highmark Inc. d/b/a Highmark Blue Shield, Highmark Benefits Group Inc., Highmark Health Insurance Company, Highmark Choice Company or Highmark Senior Health Company. Delaware: Highmark BCBSD Inc. d/b/a Highmark Blue Cross Blue Shield. West Virginia: Highmark West Virginia Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Health Insurance Company or Highmark Senior Solutions Company. Western NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Cross Blue Shield. Northeastern NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Shield.

All references to “Highmark” in this document are references to the Highmark company that is providing the member’s health benefits or health benefit administration and/or to one or more of its affiliated Blue companies.

All revisions to this Highmark Provider Manual (the “manual” or “Highmark Provider Manual”) are controlled electronically. All paper copies and screen prints are considered uncontrolled and should not be relied upon for any purpose.