Important news:

New Coordination of Benefits (COB) ruling
Effective with dates of services on or after September 1, 2009 Regence BlueShield has changed the way COB claims are processed. We are making the change to comply with a new rule issued by the Office of the Insurance Commissioner (OIC). We will no longer estimate secondary plan payments if the primary Plan’s payment amount is unknown. This new rule applies to all employer groups and Individual plans. However, Employee Retirement Income Security Act (ERISA) self-funded groups, Boeing and Medicare plans are exempt.

For more information, visit the Office of the Insurance Commissioner Web site or contact your provider consultant.

COB claims for dates of service January 1, 2008 through August 31, 2009
On January 1, 2008, Regence applied changes to our COB claims processing guidelines to comply with a new rule issued by the Office of Insurance Commissioner. This rule applied to all individual and group plans (except self-insured ERISA groups) with claims date of service on or after January 1, 2008. It included the following elements:

• The secondary payer must pay to the highest allowable between two plans.
• Claims may not be denied for primary payment information. The secondary payer must estimate the primary payment and complete processing of the claim within 45 days.

When claims are submitted without the primary allowed and paid amount Regence will call the primary insurance plan for the claim payment detail. If we are not able to obtain this information, claims will be pended for that information. The COB pended claims will show on the back of your weekly voucher in the “Claims Pending Investigation” section. If the primary insurance claim payment detail is not received by the 45th day after receipt of the claim, Regence will estimate the primary payment at 80% of our allowed amount and pay our portion of the claim.

Please include the following information on each electronic or paper claim submitted:

• Charged amount
• Primary payment
• Primary allowed amount

Use one of the three options below to submit primary payment information for a pended claim:

• Dedicated COB Fax: 1 (888) 225-4822
• Email to secure email box: cob@regence.com
• Customer service: 1 (800) 322-1737 from 6:00 a.m. to 6:00 p.m

Guidelines for Timely Submission of Claims

The following guidelines apply to all types of contracted providers and hospitals across all lines of business including government programs.

1. Original claims must be submitted within 12 months from the date of service in order to be processed.
2. Any adjustments to the original claim must be submitted within 12 months from the original process date.

NOTE: Non Par Providers, per Medicare guidelines, have 26 months from the date of service to submit a claim for Regence MedAdvantage. Any adjustment to the original claim must be submitted within 12 months from the original process date.

There might be times where an exception to above guidelines may apply (i.e. Coordination of Benefits related claim, Adjustments, etc.). A timely filing exception is not considered a Provider Appeal. You typically will be required to submit documentation for proof of a timely filing exception. If you have questions about a timely filing denial, please contact the appropriate customer service department.

Revised CMS-1500 (08-05) claim form
We will continue to accept the CMS-1500 (12-90) claim form allowing use of existing stock. Once obtained, our expectation is that you begin using the revised CMS-1500 (08-05) claim form. Obtain this revised form by contacting your current supplier. For a negative or PDF version of the revised form, direct your supplier to:

• The Government Printing Office at (202) 512-0455
• TFP Data Systems at 1500form@tfpdata.com or 1 (800) 482-9367 ext. 1770

No supplier? Visit the Web and use the term CMS-1500 to locate a form supplier today!

The CMS-1500 (08-05) claim form accommodates the National Provider Identifier (NPI) reporting. When using the CMS-1500 form it is important to note:

• Field 24J is for Type 1 NPIs (Rendering Provider)
• Field 32a is for Type 2 NPIs (Service Facility)
• Field 33a is for Type 1 or 2 NPIs (Billing Provider)

The above fields are split to allow your current Regence provider number in the shaded area and your NPI in the unshaded area labeled NPI.

Use UB-04 claim form
Regence accepts the new UB-04 (CMS-1400) which incorporates fields for the National Provider Identifier (NPI).

When using the revised form it is important to note:

• Field 56 is for the NPI of the Billing Facility/Provider
• Field 75 is for Type 1 NPIs (Attending Provider)
• Field 77 is for Type 1 NPIs (Other Referring Provider