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Electronic Claim Guidelines (ANSI 5010 837P) - Drug Field Values

Field Name Field Description Loop ID Segment​
HCPCS/CPT Procedure Code

Enter the appropriate HCPCS/CPT Code aligned with the NDC Code billed, if applicable.

• Refer to Coding a Professional Claim - NDC to HCPCS Crosswalk

2400 SV101​
HCPCS/CPT Units Enter the applicable units billed based upon the HCPCS/CPT code assigned dosage/quantity. 
The HCPCS/CPT unit must be submitted with a whole numeric value. 
(Unlisted Drug HCPCS/CPT codes do not have a specified quantity associated to the Unlisted HCPCS/CPT code. 
The HCPCS/CPT units billed should equal the number of drug containers (i.e. vial, bottle, tube) used for the services being billed.) 
**A HCPCS/CPT unit of 1 or greater must be billed on all claims**
2400 ​SV104
NDC Qualifier ​ Enter N4 in this field.​ 2410​ ​L1N02
National Drug Code (NDC)​
Enter the 11-digit NDC assigned to the drug administered/supplied (do not include hyphens/spaces).
11-digit NDC Code is required using 5-4-2 format. 
Refer to Coding a Professional Claim for converting NDC to the 11-digit format.​
2410​ ​L1N03
Monetary Amount​ Enter the Total Charge Amount for each line of service​ 2400​ SV102​
NDC Quantity   ​

Enter the NDC quantity in decimal format (up to two decimal places) based upon the reported unit of measure assigned to the NDC Code.  (NDC units billed must be converted based upon unit of measure assigned to NDC Code)

**NOTE – NDC Quantity should never be billed with a MG (ME) - milligram dosage being reported within the NDC quantity  
     • MG is not a valid unit of measure for any NDC codes. 
•  Refer to the Coding a Professional Claim – NDC Quantity for assistance on identifying the appropriate unit of measurement assigned to the NDC Code.  ​

2410​ CTP04​
Unit of Measurement (UoM)​ Enter the NDC unit of measurement associated to the billed NDC Code  (UN, ML, or GR)
• The NDC Quantity 4 units of measurement (UoM) reported for all drugs: UN, ML, GR, or F2.
     •  There are no products currently reported with the unit of measure of F2 (international unit)
• Refer to the Coding a Professional Claim – NDC Quantity for assistance on identifying the appropriate unit of measurement assigned to the NDC Code. 
2410​ CTP05​
CMS-1500 Paper Claims 
 
​Field Name Field Description CMS-1500 field ​Field Image
HCPCS/CPT Procedure Code
Enter the appropriate HCPCS/CPT Code aligned with the NDC Code billed, if applicable.
• Refer to Coding a Professional Claim – NDC to HCPCS Crosswalk
24D
 (non-shaded field)



row1.png





HCPCS/CPT Units  Enter the applicable units billed based upon the HCPCS/CPT code assigned dosage/quantity.  The HCPCS/CPT unit must be submitted with a whole numeric value.                                                                                                                     (Unlisted Drug HCPCS/CPT codes do not have a specified quantity associated to the Unlisted HCPCS/CPT.               **A HCPCS/CPT unit of 1 or greater must be billed on all claims**  
24G row2.png
NDC Qualifier, National Drug Code (NDC) and NDC Description Enter N4 in this field followed by the 11-digit NDC assigned to the drug administered/supplied (do not include hyphens/spaces) with the drug description proceeding the NDC code.
• 11-digit NDC Code is required using 5-4-2 format.  
    •  Refer to Coding a Professional Claim for converting NDC to the 11-digit format.
24A (greyed field above From-To date)


row4.png


Monetary Amount​ Enter the Total Charge Amount for each line of service 
24F​



row3.png
NDC Quantity​

Enter the NDC quantity in decimal format (up to two decimal places) based upon the reported unit of measure assigned to the NDC Code. (NDC units billed must be converted based upon unit of measure assigned to NDC Code)

**NOTE – NDC Quantity should never be billed with a MG (ME) - milligram dosage being reported within the NDC quantity  
   • MG is not a valid unit of measure for any NDC codes. 
• Refer to the Coding a Professional Claim – NDC Quantity for assistance on identifying the appropriate unit of measurement assigned to the NDC Code.  
 ​

24 D​ row5.png



Unit of Measurement (UoM)​ Enter the NDC unit of measurement associated to the billed NDC Code (UN, ML, or GR)
• The NDC Quantity 4 units of measurement (UoM) reported for all drugs: UN, ML, GR, or F2.
   • There are no products currently reported with the unit of measure of F2 (international unit)
• Refer to the Coding a Professional Claim – NDC Quantity for assistance on identifying the appropriate unit of measurement assigned to the NDC Code.  
 ​
24D (greyed field above Modifier before the NDC Quantity)​

The following is  the full sc​reenshot of the above field images reported

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Surgical Implanted Pain Medication Pumps (SIPMP) Compound Drug Billing Guidelines
The following billing guidelines must be followed when submitting claims for SIPMP compounded drug(s) refills in order to prevent the services from denying or being underpaid. 
• All services related to the SIPMP refill, programming, drug(s), and compounding must be submitted on the same claim for each date of service in order to be services from being denied or prevent a delay in payment.
• Each compounded drug(s) used for the SIPMP refill must be submitted on a separate line of the claim with the 11-digit NDC Code assigned to each of the drug(s) used in the SIPMP refill.
• The accurate NDC quantity (with the amount converted based upon the NDC assigned unit of measure) must be submitted in the metric decimal quantity (up to 2 decimal spaces – i.e. 0.01)
        • When the NDC quantity is converted and the metric decimal quantity is less than 2 decimal places, the NDC quantity must be rounded up to 0.01.  (i.e. 0.007, 0.0012, 0.0004, etc)
         • All compounded powder NDC codes are assigned a GR (Gram) unit of measurement, so the NDC quantity submitted must be for quantity amount based upon GR (Gram) unit of measure rounded up to 2 decimal quantities. 
• If applicable, Florida Blue will allow a single ‘compounding fee’ up to $70.00 when submitted and billed appropriately.  The compounding fee is reimbursing for any fees and/or supplies charges by the compounding pharmacy.  
        • In order to be considered for payment of the compounding fee, the following instructions must be used when submitting the claim:
                 • A separate line must be billed using the following data elements: 
                       • HCPCS code = J3490
                       • NDC code = 00000000070
                       • NDC quantity = 1
                       • HCPCS quantity = 1
The following is an example to provide guidance with submitting an electronic and paper claim: 
• The following identifies the information that may be referenced on the invoice received from the compounding pharmacy identifying the drug and amounts used for the patient that came into the office 04/17/2014 to have their SIPMP programmed and refilled:
**Invoice Example #1 
​Quantity Description​ Rate​ Amount
 
Delivery 04/15/2014 – patent, name  *20cc pump*
   ​
2,000​ Fentanyl 10mcg/ml (NDC 38779-1756-06)​ 0.42 $40.00
200 Hydromorphone 20mg/ml (NDC 38779-0731-05)​ 0.37 $74.00
300 Bupivacaine 15mg/ml (NDC 38779-0524-05) 0.06 $18.00​
Supplies​ $10.00​
Compounding Fee​ $25.00​
$167.00​

 

Based on the above information noted on the example above, the following identifies how the claims should be submitted for each services provided for the date of service

 

Claim Field Name Claim Field Description & Guidelines​ Electronic Claim Loop ID​ Electronic Claim Segment​ CMS-1500 Form Field​ CMS-1500 Form Images
HCPCS/CPT Procedure Code​

 The appropriate HCPCS/CPT code(s) must be submitted for each service being billed on a separate claim line. 

For drug services billed, the HCPCS/CPT code aligned with the NDC must be submitted.  Refer to NDC to HCPCS Crosswalk section of the Provider Manual

NOTE – All SIPMP drug supplied by the manufacture in bulk powders must be billed with J3490

 2400 SV101​ 24D​  ​







row1.png



HCPCS/CPT Units
HCPCS/CPT quantity amount
Enter the applicable units billed based upon the HCPCS/CPT code assigned dosage/quantity. 
(Unlisted Drug HCPCS/CPT codes do not have a specified quantity associated to the Unlisted HCPCS/CPT code. The HCPCS/CPT units billed should equal the number of drug containers (i.e. vial, bottle, tube) used for the services being billed.)                                                                                                                                                    
NOTE - A HCPCS/CPT unit of 1 or greater must be billed on all claims
 
2400 ​SV104 ​24G row2.png

Monetary Amount Enter the Total Charge Amount for each line of service 2400 ​SV102 ​24F










row3.png


NDC Qualifier Enter N4 in this field 2410

LIN02​

National Drug Code (NDC) and NDC Description​ Enter the 11-digit NDC assigned to the drug administered/supplied (do not include hyphens/spaces).
• 11-digit NDC Code is required using 5-4-2 format.  
        •  Refer to Coding a Professional Claim for converting NDC to the 11-digit format. 
2410​ LIN03​ 24A (greyed field above From-To date)​​




row4.png










NDC Quantity​ The metric decimal quantity (rounded up to 2 decimal places) must be submitted on each SIPMP compounded drug based Gram unit of measure.  In the event the metric decimal amount is lower than 0.01, the NDC quantity must be rounded up to 0.01 (i.e. 0.004, 0.0021. 0.0006, etc)
In order to accurately report the NDC quantity, you must multiple the pump size by the drug quantity, then convert the quantity based upon Gram (GR).  The following are the examples based upon the sample invoice above which identifies the pump size as 20cc:
• Fentanyl 10mcg/ml (NDC 38779-1756-06)
      • 10mcg * 20cc = 200mcg
      • Convert quantity based Gram unit of measure = 0.0002 (since the quantity is less than 0.01, the NDC Quantity billed must be rounded up) 0.01 GR (grams – NDC quantity billed)  
• Hydromorphone 20mg/ml (NDC 38779-0731-05)
      • 20mg * 20cc = 400mg
      • Convert quantity based on Gram unit of measure = 0.4 GR (Grams - NDC quantity amount billed)
• Bupivacaine 15mg/ml (NDC 38779-0524-05)
      • 15mg * 20cc = 300mg
      • Convert quantity based on Grams unit of measure = 0.3 GR (Grams – NDC quantity billed)
2410​ ​CTP04 24D (greyed field above Modifier)​ row5.png







Unit of Measurement (UoM)​
Each NDC quantity amount billed for the different SIPMP powders that are compounded must be billed based upon the GR (gram) unit of measure
 
**NOTE – NDC Quantity should never be billed with a MG (ME) - milligram dosage being reported within the NDC quantity 
 • MG is not a valid unit of measure for any NDC codes. 
Refer to the Coding a Professional Claim – NDC Quantity for assistance on identifying the appropriate unit of measurement assigned to the NDC Code. 
 
Below are examples of a paper claim submission identifying the detail lines billed for a single date of service based on the invoice samples.  Paper Claim Submission based on invoice Example #1 (referenced above)



row6.png


Invoice Example #2
 
Order Item Number​ Description​ Charge​
1​  
H6B20

 Morphine Sulfate (NDC 38779-0673-03)  15mg/ml / Baclofen
(NDC: 38779-0388-03) 450 mcg/ml

40 cc pump

Example#2, Patient

 ​$610.00
  xxx​ Compounding Fee $55.00
       
     Total $665.00
 
• To determine the appropriate NDC Quantity:
• Multiple the dosage for each drug by the size of the pump
    • Morphine Sulfate (15mg * 40cc) = 600mg
    • Baclofen (450mcg * 40cc) = 18000mcg
• Convert the quantity into Grams
    • Morphine Sulfate 600mg = 0.6 grams
    • Baclofen 18000mcg = 0.018 grams (round up to 2 decimal place 0.02 grams)
 
 

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Advanced Non-Physician Practitioners

Registration and Credentialing
Florida Blue and Health Options currently define Advanced Non-Physician Practitioners as ARNPs, CNMs, CNSs, PAs, and RNFAs who practice independently or as associated members of a physician association. Florida Blue may expand this definition in the future to include other provider types.
Advanced Non-Physician Practitioners, as defined above, are required to obtain a Florida Blue provider number, and register their NPI number with Florida Blue.
It is the physician’s, physician groups, or facility’s responsibility to ensure that any employed or contracted Advanced Non-Physician Practitioners is properly licensed and supervised as defined in Florida Statues 458.347 (1) (f) and 464.012, respectively. They are also responsible for ensuring that employed Advanced Non-Physician Practitioners maintain proper licenses and credentials. Additionally they must ensure that each Advanced Non-Physician Practitioners is registered with Florida Blue.
Claim Submission Requirements
Physician Extender services should be billed with the extender’s NPI or Florida Blue number in block 24J on the CMS-1500 as the rendering provider.
Florida Blue requires a separate claim for each rendering provider. A single service rendered by two or more providers for the same member on the same date of service must be billed with the provider who performed the substantive portion of the service in block 24J. Illustrative examples are listed below:
  • If the Physician Extender performs the history and physical and the physician evaluates the patient’s medical condition, orders tests, and develops a treatment plan, then the service should be billed with the physician as the rendering provider.
  • If the Physician Extender performs the history and physical, evaluates the patient’s medical condition, orders tests, and develops the treatment plan and the physician enters the examination room to confirm the diagnosis and treatment plan, then the service should be billed with the Physician Extender as the rendering provider.
Physician Extenders should not submit claims under the following circumstances:
  • Services were not personally performed. The supervision of other staff does not constitute a personally performed professional service.
  • A facility, hospital, or birthing center is paid an allowance for the extender’s professional services.
Claims submitted are an attestation of services performed. Florida Blue reserves the right to conduct audits and/or reviews to ensure claims are submitted appropriately.
Payment for Covered Services
Where contractual language allows, covered services rendered by physician extenders not directly contracted with Florida Blue will be reimbursed at 85 percent of the contracted provider’s rate where a RVU exists. Physician Extenders directly contracted with Florida Blue will be reimbursed at the contracted rate.
Surgical first assist services by a licensed physician extender should be billed by the employing physician, group, employer or clinic with the addition of modifier AS and the physician extender NPI or Florida Blue provider number entered in block 24J as the rendering provider. Florida Blue will reimburse these services at 20 percent of the allowed amount when the service is covered and the surgery warrants a surgical assistant. Effective January 1, 2011, BCBSF will reimburse these services at 16 percent of the allowed amount when the service is covered and the surgery warrants a surgical assistant.

Substitute Physicians

A substitute physician, sometimes called a locum tenens physician, is a physician who is hired to temporarily replace another physician ("usual" physician).  The usual physician may be absent for reasons such as illness, pregnancy, vacation or continuing medical education.  This absence should not exceed 60-days unless the usual physician has been called to active duty in the Armed Forces.  The usual physician bills and receives payment for the substitute (locum tenens) physician's services as though the usual physician performed the services.  The usual physician is responsible for reimbursing the substitute (locum tenens) physician for services rendered and ensures that the substitute (locum tenens) physician shall not bill or seek payment from the member.  The usual physician identifies the reported services as locum tenens physician services by entering code modifier Q6 (service furnished by a locum tenens physician) after the procedure code on the CMS-1500 claim form. 

National Provider Identifier (NPI)

The NPI must be submitted on all electronic claims, and must be submitted through the Availity® Health Information Network. You may access Availity directly or send your claims through a billing service or clearinghouse to transmit to Availity.  Availity will then route to Florida Blue 
For detailed billing instructions on how to submit the NPI properly, please refer to Version 5010 Updates and Helpful Tips.

Paper Claims Submission

Filing your claims electronically is both quicker and more cost effective. However, there may be times when it is necessary to file paper claims. The CMS-1500 (or equivalent) and the UB-04 are the claim forms accepted by Florida Blue.
CMS-1500
The NUCC determines the data elements and design of the CMS-1500. For additional information, including instructions on completing the form, refer to www.nucc.org.
UB-04
The NUBC and the Florida State Uniform Billing Committee SUBC determine the data elements and design of the UB-04. These data elements are published in the National Uniform Billing Data Element Specifications Manual, which contains instructions for completing the UB-04 claim form.
If you would like to enroll in the UB-04 subscription service to receive a complete UB-04 manual and updates, visit www.nubc.org. You may also contact the Florida Hospital Association Management Corporation at www.fha.org.
OCR
Florida Blue uses OCR scanning equipment to process paper claims. OCR is an automated system that reads and interprets the characters in each block submitted on the claim form. The information is then sent into the claims processing system. The more accurately the claim is completed, the less manual intervention is necessary.
The following guidelines will help in preparing paper claims for OCR scanning:
  • Form: Print the claim information in black ink on a blank, red ink CMS-1500 or UB-04 form. You may also use software programs, which print both the form and the claim information in black ink. Do not fold, staple or tape your claim.
  • Alignment: Align all information within the designated field.
  • Font: Use upper case letters in Courier font, size 10 (CMS-1500) or size 12 (UB-04). Do not bold or italicize font.
  • Characters: Do not use special characters (e.g., dollar signs, decimals, dashes, zeros or sevens with slashes).
  • Names: Omit any titles, such as “Mr.” or “Mrs.” Enter the last name first, followed by a comma, then the first name.
  • Dates: Use an eight-digit format for dates and do not space between numbers (e.g., enter June 15, 2008 as 06152008).
  • Time: Use a four-digit format for time; referred to as “units” in block 24G (e.g., enter 1 hour 30 minutes as 0130).
Rejected Claims
All paper claims go through “front-end” edits that verify eligibility information. Claims that cannot be scanned by OCR will be returned to the provider with an accompanying explanation. If the claim is returned, it must be submitted as a new claim; not a “corrected” claim. Returned claims are rejected prior to processing; therefore, there is not an original claim to correct in the system.
Medicare Advantage (HMO and PPO) Data Requirements
Providers must either submit a CMS-1500 (or equivalent) or UB-04 paper claim form with all the information that is required for original Medicare submission or file the required data electronically. Failure to complete all required information could result in the claim rejecting, payment delays, and/or additional development requests. Refer to the Participating Provider Responsibilities for additional information on encounter data reporting requirements.
CMS-1500:
  • Patient’s name (block 2)
  • Insured’s name (block 4)
  • Member ID number (block 1a)
  • Patient relationship to member (block 6)
  • Patient date of birth (block 3)
  • Date of service (block 24A)
  • CPT procedure codes with modifiers when appropriate (block 24D)
  • ICD diagnosis code(s) to highest level of specificity (block 21)
  • Place of service (block 24B)
  • Unit(s) of service (block 24G)
  • Charge(s) (block 24F)
  • Performing provider's individual number or professional association (PA) NPI, if applicable (block 24J)
  • Federal Tax ID number (block 25)
  • Provider of service signature (block 31)
  • Billing provider’s information and phone (block 33)
  • Billing provider’s NPI, if applicable (block 33a)
  • Billing provider’s other ID number (i.e., Florida Blue provider number), if applicable (block 33b)
UB-04:
  • Provider name (field 1)
  • Type of bill (field 4)
  • Federal Tax ID number (field 5)
  • Statement covers period (field 6)
  • Patient name (field 8)
  • Patient address (field 9)
  • Patient birth date (field 10)
  • Patient sex (field 11)
  • Admission date (field 12)
  • Admission hour (field 13)
  • Type of admission (field 14)
  • Source of admission (field 15)
  • Discharge hour (field 16)
  • Patient status (field 17)
  • Condition codes (fields 18-28)
  • Value codes and amounts (fields 39-41)
  • Revenue code (field 42)
  • HCPCS/Accommodation Rates/HIPPS rate codes (field 44)
  • Payer name (field 50)
  • Health plan ID (field 51)
  • Insured’s name (field 58)
  • Patient’s relationship (field 59)
  • Insured’s unique ID (field 60)
  • Treatment authorization code (field 63) 
  • Principal diagnosis code and POA indicator (field 67)
  • Other diagnosis codes (field 67A-Q)
  • Admitting diagnosis (field 69)
  • Attending NPI/QUAL/ID/Last/First (field 76)
  • Home Health providers treating Medicare Advantage members should ensure the Treatment Authorization Code and the HIPPS Home Health Resource Group code is submitted on the claim. Refer to your provider agreement to ensure you are billing according to the terms and condition of your contract. If contracted against a Florida Blue payment program for Medicare Advantage members, then Original Medicare billing requirements do not apply. If contracted against the Medicare Prospective Payment System, then ensure Original Medicare billing requirements are used for claim submissions. Refer to the BlueCard Program Manual for proper billing of out-of-state BlueCard member claims to Florida Blue.
  • SNFs treating Medicare Advantage members should ensure the HIPPS Resource Utilization Group code is submitted on the claim. Refer to your provider agreement to ensure you are billing according to the terms and condition of your contract. If contracted against a Florida Blue payment program for Medicare Advantage members, then Original Medicare billing requirements do not apply. If contracted against the Medicare Prospective Payment System, then ensure Original Medicare billing requirements are used for claim submissions. Refer to the BlueCard Program Manual for proper billing of out-of-state BlueCard member claims to Florida Blue.
  • Inpatient Rehabilitation Facilities treating Medicare Advantage members should ensure the HIPPS Case Mix Grouping code is submitted on the claim. Refer to your provider contract to ensure you are billing Florida Blue according to your contract terms. If contracted against a Florida Blue payment program for Medicare Advantage members, then Original Medicare billing requirements do not apply. If contracted against the Medicare Prospective Payment System, then ensure Original Medicare billing requirements are used for claim submissions. Refer to the BlueCard Program Manual for proper billing of out-of-state BlueCard member claims to Florida Blue.
  • BlueMedicare products do not reimburse services in the same format as may be required by Original Medicare Part A and Part B. Do not separate Medicare Part A and Part B charges as you would when billing Original Medicare for a Medicare Part A exhausted benefit claim. For example, claims for inpatient hospital/facility services should be submitted to Florida Blue, as Florida Blue is the primary payer and not Medicare even though it is an Original Medicare replacement product. This means all charges should be submitted to Florida Blue as eligible Medicare Part A charges.

Medicare Supplement Claims

  • Medicare Supplement claims should be filed initially to Medicare with Florida Blue indicated as the supplemental carrier. Medicare will usually automatically crossover claims to Florida Blue for any applicable deductible and coinsurance amounts. Claim information will not be crossed over to Florida Blue until after Medicare has processed the claim and released it from the Medicare payment hold.
    After receipt of the Medicare Remittance Notice, review the indicators to identify whether the claim was crossed over directly to Florida Blue.
  • If the indicator shows the claim crossed over, Medicare has submitted the claim to Florida Blue and the claim is in progress. You do not need to take further action. The 835 electronic remittance advice record can also carry the secondary forwarding information. 
    You will receive payment or processing information from Florida Blue after we receive the Medicare Remittance Advice. Please allow 45-days from the primary payment date for the processing of the secondary claim.
  • If the claim did not crossover automatically, then file the claim to Florida Blue with the Medicare Remittance Notice attached. It is important that you allow 45-days after you receive the Medicare Remittance Notice before filing the Medicare Supplement insurance coverage claim.
  • IMPORTANT: Allow 45 days after you receive the Medicare Remittance Notice before filing the Medicare Supplement insurance coverage claim.

     

    If after 45 days, you haven’t received payment and desire to submit your claim (electronic or paper), it’s important that you include the Medicare Report Number and Medicare Remittance Advice Information.
    Participating Medicare Select providers have agreed to accept the Medicare allowed amount as payment-in-full for covered services.

     

Claim Documentation Requests

When additional documentation is required to process a claim, Florida Blue will fax or mail a written request to you. The request will include a letter and a routing sheet for a specific claim. The letter contains the key data from the claim (i.e., patient name, member number, patient account number and claim number), information requested, and the reason additional information is needed. This routing sheet serves as the fax cover sheet or cover page for documents that are mailed back to Florida Blue and is used for tracking purposes.
The following are tips for submitting claim documentation when it is requested:
  • The Routing Sheet must be only used for the matching documentation. Do not copy the Routing Sheet for multiple claims; it is for a specific claim and member.
  • The Routing Sheet must always be the top sheet attached to the documentation regardless of the mode of return (i.e., fax, mail).
  • When the documentation is returned by fax, the Routing Sheet must be fed from the top of the page to the bottom of the page.
  • Do not attach separate sets together. Fax one information package at a time. Our electronic receiving system only recognizes the first page as the Routing Sheet and catalogues all subsequent pages accordingly.
  • Do not write on the Routing Sheet except to place an “X” within the applicable boxes to designate what type of documentation is attached to the Routing Sheet.
  • For records that contain greater than 100 pages, mail the documentation to P.O. Box 1798, Jacksonville, Florida 32231-0014. Package it with the Routing Sheet as the first page.
  • Do not send double-sided copies.
  • Do not return the original letter that was sent with the Routing Sheet.

Helpful Claims Filing Hints

To prevent claims processing and payment delays, follow the claims filing hints below:
  • Verify coverage. Groups often have changes in their health insurance benefit plans. Make re-verifying coverage through Availity or the telephone self-service option a routine part of your practice.
  • Submit the entire member ID number including alpha prefix. Submit the member ID number not the member's Social Security number. Remember to correct your billing system when there are changes. The 835 electronic remittance advice will indicate when a member’s identification (ID) number is processed with a different identifier than was submitted.
  • Complete all claim entry fields. To receive proper reimbursement, the claim information must be completed in its entirety. Incomplete or inaccurate information will result in a claim denial.
  • Enter the date of onset, if applicable. All ICD diagnosis codes in the 800-900 range require a date of onset (injury, accident, first symptom, etc.).
  • Use valid codes. CPT, HCPCS, and ICD codes are updated quarterly. Make sure you or your billing service is using the most up-to-date codes.
  • Report an unlisted code only if unable to find a procedure code that closely relates to or accurately describes the service performed. Unlisted codes require documentation and therefore cannot be submitted electronically.
  • Use diagnosis codes that indicate a general medical exam when billing for “preventive” health screening exams. Claims for these services will be denied if other diagnosis codes are used.
  • Submit modifiers affecting reimbursement in the first and second position on claims. A procedure code modifier, when applicable, provides important additional information about the service performed.
  • Submit multiple procedures on one claim. All procedures performed on the same date of service, by the same provider for the same patient should be submitted on one claim.
  • Submit all applicable diagnosis codes. Code to the highest level of specificity possible. Most 3-digit codes require a fourth or fifth digit.
  • Include the NPI for rendering physician and billing physician or group. Both the CMS-1500 and UB-04 include fields for the NPI.
CMS-1500:
  • Block 24J is for Type 1 NPIs (Rendering Physician)
  • Block 32A is for Type 2 NPIs (Service Facility)
  • Block 33 A is for Type 1 or 2 NPIs (Billing Physician/Group)
The above blocks are split to allow your Florida Blue provider number in the shaded area and your NPI in the non-shaded area labeled NPI.
UB-04:
  • Field 56 is for the NPI of the Billing Facility/Provider
  • Field 76 is for Type 1 NPIs (Attending Provider)
  • Field 78 and 79 are for Type 1 NPIs (Other referring provider)
  • Use the correct Tax ID or Social Security number. For participating providers, the Tax ID number (TIN) reported on the claim should match the TIN found within the provider agreement, which is the provider/legal entity's payee TIN. Should your legal entity TIN change, please contact your Florida Blue Network Manager directly before claims are submitted containing this new information.
  • When services are rendered in a facility that is NOT associated with the billing entity, enter name and address along with NPI if available.
    • Valid 9-digit zip codes are required.
  • Submit the correct billing provider information.
    • Individual Physicians/Providers: Enter the name, address, phone number, and NPI of the individual physician, if services were rendered in a solo practice.
    • Groups: Enter the name, address, phone number and NPI of the group practice
    • Valid 9-digit zip codes are required.
      Note: Billing provider address is the location where services were rendered and MUST be a street address.  For electronic submissions, if the payment address is different than the billing address, submit in the “Pay To” including any P.O. Box.
  • Avoid sending duplicate claims. For claims status, use Availity or contact Florida Blue. If filing electronically, be sure to also check your Availity file acknowledgement and EBR for claim level failures. Allow 15-days for electronic claims and 30-days for paper claims before resubmitting.
  • Corrected claims. If you do not submit your corrected claims electronically, then indicate “Additional Services” on claims when billing for additions to the original claim. This will clearly distinguish your claim as being filed in addition to the original, but not replacing the original claim (i.e., a corrected claim). The additional services must be submitted on a paper claim form.
  • Taxonomy Code. Claims should contain the proper provider taxonomy code, especially for MA members. 
  • NPI and Sub-part Identifiers. Claims should also contain the proper NPI for sub-units of a hospital, if applicable, especially for MA members or if the sub-unit is a participating with Florida Blue. If a NPI was not obtained for sub-units of the hospital, ensure the proper taxonomy code is used when billing Florida Blue. 

Timely Filing

Providers must file claims within the time set forth in their Florida Blue participating provider Agreement(s) unless applicable law requires a greater time period for filing of claims. If applicable to a particular benefit agreement, current Florida law and other legal requirements provide that claims must be filed within 180 days after the date of service and receipt by the provider of the name and address of a patient’s health insurer.
Provider should submit claims indicating their usual fees for services rendered. Florida Blue will make appropriate adjustments based on the contractual agreement.
Florida Blue complies with applicable legislation regarding timeliness of filing and processing claims.

Claim Inquiries

Providers may submit inquiries on claims for a variety of reasons (e.g., corrected claims, late charges, medical records, etc.). When submitting a claim inquiry, complete the Provider Claim Inquiry Form and attach it to your claim.
Corrected Claims
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.
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.
Note: Florida Blue does not consider a corrected claim to be an appeal.
When submitting a paper 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.
  • If a modifier 25 or 59 is being appended to a CPT code that was on the original claim, do no 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).
  • Attach the completed Provider Claim Inquiry Form with your corrected claim.
When submitting an electronic corrected claim through Availity, use the Bill and Frequency Type codes listed below:
7 – Replacement of Prior Claim
  • If you have omitted charges or changed claim information (diagnosis codes, dates of service, member information, etc.), resubmit the entire claim, including all previous information and any corrected or additional information. Hospitals and facilities should include the seven in the third digit of the Bill Type. Physicians should submit with a Frequency Type code of seven.
8 – Void/Cancel of Prior Claim
  • If you have submitted a claim to Florida Blue in error, resubmit the entire claim. Hospitals and facilities should include the eight in the third digit of    the Bill Type. Providers should submit with a Frequency Type code of eight if the claim was paid, resubmit the claim to Florida Blue via paper and attach a check for the amount that was paid in error.
Claim Reconsiderations
If the Provider wants Florida Blue to reconsider the claim adjudication decision documented on the Remittance Advice they may request a Reconsideration. Providers may submit Reconsiderations for a variety of reasons (e.g., claim allowance, coordination of benefits, provider contract issue, etc.). When submitting a claim Reconsideration, complete the Provider Inquiry / Reconsideration Form, check the Provider Reconsideration box at the top of the form, and attach any supporting documentation. These claim reconsiderations may also be requested via the telephone if no medical records or supporting documentation is required. When Florida Blue has completed its review of the Reconsideration request the provider will be notified of the decision via letter. If the Provider is not satisfied with the Reconsideration decision, they may access the Florida Blue website and file an Administrative Appeal.
Note: A Reconsideration must be completed by the Provider before an Administrative Appeal can be submitted.

Claim Filing Addresses

 

Submit paper claims to the following address (exceptions, see Dedicated Service Units): 
Florida Blue​
P.O. Box 1798
Jacksonville, FL 32231-0014

 

Dedicated Service Units
Send claims and correspondence for the following groups and product lines to the addresses below.
Atlantic, Quebec & Ontario Blue Cross

 

Canadian Travel Insurance
Florida Blue
P.O. Box 45149

 

Jacksonville, FL 32232-5149

 

State Employees’ PPO Plan

 

Florida Blue
P.O. Box 2896
Jacksonville, FL 32232-0079

 

Medicare Supplement

 

Florida Blue
P.O. Box 44160
Jacksonville, FL 32231-4160

 

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10/30/2014
The Manual is not intended to be a complete statement of all BCBSF polices or procedures for providers. Other policies and procedures, not included in this Manual, may be posted on our website or published in special publications, including but not limited to, letters, bulletins, or newsletters. Any section of this Manual may be updated at any time. In the event of any inconsistency between information contained in this Manual and the agreement(s) between you or your facility and BCBSF or Health Options the terms of such agreement(s) shall govern.

The Manual is not intended to be a complete statement of all Florida Blue polices or procedures for providers. Other policies and procedures, not included in this Manual, may be posted on our website or published in special publications, including but not limited to, letters, bulletins, or newsletters. Any section of this Manual may be updated at any time. In the event of any inconsistency between information contained in this Manual and the agreement(s) between you or your facility and Florida Blue or Health Options the terms of such agreement(s) shall govern.

Refer to the References section to view all applicable copyrights, registered trademarks, service marks, and/or references. Acronyms are also defined in the References section.

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