Tips for Filing Inquiries, Corrected Claims and Provider Appeals from BCBS

Inquiries

When submitting an inquiry regarding corrected claims, questions about late charges, medical records or other situations, remember to complete the Provider Claim Inquiry Form and attach it to your claim. You should use this form for claims that denied with reason code CADEV (contest/additional information) and INFNR (claim denied, requested information not received or incomplete.) Please do not submit these denials with a Provider Appeal form.

A corrected claim is a claim that has already been processed, whether paid or denied, and is resubmitted with additional charges, different procedure or diagnosis codes or any information that would change the way the claim originally processed.

For a copy of the Provider Claim Inquiry Form Click Here, or visit our website at www.floridablue.com, select the Providers tab, then Tools & Resources.

Filing Corrected Claims

When submitting a corrected claim, follow these steps:

• Submit a copy of the remittance advice with the correction clearly noted.

• If necessary, attach requested documentation (e.g., nurses’ notes, pathology report) along with the copy of the remittance advice. To ensure documents are readable, do not send colored paper or double-sided copies.

• Boldly and clearly mark the claim as “Corrected Claim.” Failure to mark your claim appropriately may result in rejection as a duplicate.

• Attach the completed Provider Claim Inquiry Form with your corrected claim.

• If a modifier 25 or 59 is being appended to a procedure code that was on the original claim, do not submit as a "Corrected Claim." Instead, submit as a coding and payment rule appeal with the completed Provider Appeal Form and supporting medical documentation (e.g., operative report, physician orders, history and physical).

• Claims returned requesting additional information or documentation should not be submitted as corrected claims. While these claims have been processed, additional information is needed to finalize payment.

Send paper corrected claims or inquiries to:

Florida Blue

P.O. Box 1798

Jacksonville, Florida 32231-0014

Provider Appeals

Providers may request reconsideration of how a claim processed, paid or denied. These requests are referred to as appeals. There are four different types of appeals. Each type may be reviewed in detail in the online Provider Manual at http://providermanual.bcbsfl.com/ARS/Appeals/Pages/default.aspx.

• Coding and Payment Rule Appeals

• Utilization Management Appeals

• Adverse Determination Appeals

• All Others