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December 14, 2015

New Blue KC Electronic Claim (837) Edit - Effective Monday, January 18, 2016

Blue Cross and Blue Shield of Kansas City (Blue KC) is adding a new eligibility edit to help ensure that electronic claims are submitted with the correct member name, member date of birth, and member ID number. The new eligibility edit applies to all Blue KC lines of business except for BlueCard (ITS) and Federal Employee Program (FEP).

To ensure your claim complies with this new edit and does not reject, please make sure your claim contains the correct member name and member ID number off the member ID card along with the correct date of birth.

Technical Overview – New Electronic Claim Edit:

  • The new edit will look for a match not only on member ID, but also on the first 5 characters of the first name and date of birth of the Subscriber Level Loops 2000B / 2010BA and Patient Level Loops 2000C / 2010CA.
  • Below are edit details depending how the Subscriber and Patient loops are sent on the electronic claim:
    • Subscriber only loop is present on claim – first 5 characters of the subscriber first name and date of birth must match the member ID number submitted.
    • Subscriber and Patient loop is present on claim – the subscriber and patient are the same on the claim…first 5 characters of the patient first name and date of birth must match the member ID number submitted.
    • Subscriber and Patient loop is present on claim – the subscriber and patient are NOT the same on the claim…first 5 characters of the patient first name and date of birth must match the member ID number submitted.

Electronic Claim Scenarios and Claim Reject Examples

Electronic Claim (837) Claim Scenarios

If no match from Claim Scenarios – Claim will Reject for the following 277CA Edit Code

Edit Logic

If the subscriber only loop is present or the subscriber and patient are the same on the claim – first 5 characters of the subscriber / patient first name must match the member ID submitted.

A7:505:IL “Reject for entity's first name”

When the subscriber is the patient: the first 5 characters of the subscriber first name 2010BA / NM104 must match the member ID number submitted.

If the subscriber only loop is present or subscriber and patient are the same on the claim – the subscriber / patient date of birth must match the member ID submitted.

A7:158:IL “Reject for entity's date of birth”

When the subscriber is the patient: the date of birth 2010BA / DMG02 must match the member ID number submitted.

If the subscriber and patient loop is present and the subscriber and patient are NOT the same on the claim – first 5 characters of the patient first name must match the member ID submitted.

A7:505:QC “Reject for entity's first name”

When the patient is not the subscriber: the first 5 characters of the patient first name 2010CA / NM104 must match the member ID number submitted.

If the subscriber and patient loop is present and the subscriber and patient are NOT the same on the claim – the date of birth of the patient must match the member ID submitted.

A7:158:QC “Reject for entity's date of birth”

When the patient is not the subscriber: the date of birth 2010CA / DMG02 must match the member ID number submitted.

If you have questions, please contact your Blue KC Provider Relations Representative.

 

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