Chapter 7 Submit a Claim

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This section contains the following information:

Submitting Claims to BCCP
Provider Reimbursement Requirements
Provider Reimbursement Rates
Enrollment/Eligibility Determination and Client Tracking
Denial of Reimbursement
Submit Claims in the Web Data System
Check Claim Status
Claims processing

Submitting Claims to BCCP

The BCCP requires that client claims are submitted electronically using the Web Data System. Users enter claim information, check processing status, and generate Explanation of Benefit (EOB) documents using the system.

Provider Reimbursement Requirements

The BCCP must have a signed Medical Services Agreement with the provider.
The provider must maintain documentation in the client's medical record of BCCP services provided.
For those clients who are underinsured, the provider must first submit claims to a client's private insurer. If a third-party payer covers a portion of the cost of the screening services, the provider may not bill the BCCP for the remaining costs. The BCCP does not reimburse for co-payments.
Providers must accept BCCP reimbursement rates for billed procedures as payment in full. Providers may not bill BCCP clients for remaining balances of procedures reimbursed by BCCP. Providers may bill BCCP clients for procedures that are not covered by the BCCP, but providers must inform clients in advance and in writing that a specific procedure will not be covered by the program.
Providers may only submit claims for completed services.
The type of screening must be identified on all claims submitted for reimbursement along with the CPT and ICD-9 codes.

Provider Reimbursement Rates

Reimbursement rates for the Oregon Breast and Cervical Cancer Program are determined using the current Medicare Reimbursement Rates for the Portland Metro Area.
Reimbursement rates for BCCP are updated annually.
The BCCP will not pay for more than one office visit code per date, per individual provider.
The BCCP is the payer of last resort.

CPT Code List and Provider Reimbursement Schedule

For a list of current reimbursement rates and the approved CPT codes, see www.healthoregon.org/bcc.

Enrollment/Eligibility Determination and Client Tracking

A Data Collection Fee for client Enrollment/Eligibility determination and client tracking is reimbursed at $25 per client.

This fee is only paid once for a client within a one-year period.

If a client had been lost to follow-up, refused services or leaves the program for any reason and re-enrolls before 12 months from her first enrollment, the fee is not paid a second time.
If a client had been lost to follow-up, refused services or leaves the program for any reason and re-enrolls more than 12 months from her first enrollment, the fee will be paid.
The Data Collection Fee must be documented separately, and is not paid until all required data are received.

Denial of Reimbursement

All services must be billed by submitting claim information in the method specified by the BCCP. Claims will be denied for any of the following reasons:

Services provided to ineligible client (that is, a client who does not meet the age, income, insurance or screening frequency and/or screening interval requirements.)
Services provided to a client who is not enrolled in the BCCP.
The claim is submitted more than 12 months after the date of service.
No payment will be made for any expense incurred for any of the following services or items:
Treatment for cancer or pre-cancerous conditions.
Any other medical service or laboratory tests whose primary purpose is for a reason other than breast or cervical cancer screening or diagnostic testing.

Submit Claims in the Web Data System

File claims with BCCP to get reimbursed for the services you provide to eligible clients. A unique transaction control number (TCN) is assigned to each incoming claim. This number is designed to identify all related claim items as part of a single claim.

To file a claim:

On the main menu, click Claims.

The Claims opening screen appears.

Find the record for the client for whom you provided a service by clicking either Client Search or TCN Search on the Actions menu.

You can search by client information or by transaction control number (TCN).

Enter the claim information. Fill in all the fields in the form. Fields that are required are labeled in red. Detailed information about each field follows. Use Tab to move to the next field when you have completed a field.
Click Submit to save the claim and submit it for reimbursement.

Find a client record

Find the client record for the client for whom you wish to submit a claim.

To find a client record:

On the Actions menu, click either Client Search or TCN Search.

For instructions on finding a client record using client information, see Find a Client Record (Client Search).

To find a client record using a transaction control number (TCN):

Enter the transaction control number, and then click on Find.

Review Client Information

Review the client information section to make sure that the services have not already been submitted to BCCP.

Use the following field guidelines to interpret TCN history.

Field name	Description	Notes
Transaction Control Number	Choose a Transaction Control number by clicking on the drop-down menu and selecting the appropriate row or entering/selecting the appropriate number.	A unique transaction control number (TCN) is assigned to each incoming claim. This number is designed to identify all related claim items as part of a single claim
Claim Status	The status of the claim indicated will match the Transaction Control number originally selected.	PA = Processed, all CPTs have been paid. PS = Processed, some CPTs have been paid. PN = Processed, no CPTs paid; all denied. VO = Voided. PE = Pending; Claim not yet processed.
Billing Site	The site where all payments are sent to for reimbursed services.
Date of 1st CPT	The first date of service on the claim.

Enter claim information

To enter a new claim:

Choose New Claim from the Actions menu.

The Claim Information screen appears.





Enter the claim information. Use the following field guidelines when entering in claims.

Field name	Description	Notes
Date of service	The date the service or procedure was done. Enter the date in MM/DD/YYYY format. For example, 01/01/2008.	This is a required field.
Place of service	The location where the service was done.
CPT Code	The service or procedure that was done.	This is a required field. Claims submitted must have an acceptable CPT code to be reimbursed. Check the BCCP Web site (www.healthoregon.org/BCC) for the most up-to-date list of reimbursable CPT codes.
Modifier 1
Modifier 2
Primary diagnosis code	The diagnosis code for the procedure that was performed. Enter the five-digit code without the period. For example v25.09 should be entered V2509.	This is a required field. Claims submitted must have an acceptable ICD-9 code as the primary diagnosis code to be reimbursed. Check the BCCP Web site (www.healthoregon.org/BCC) for the most up-to-date list of reimbursable ICD-9 codes. Diagnosis codes cannot include a period.
Additional diagnosis code	Use this to enter any additional diagnosis.	Up to three additional diagnosis codes are allowed.
Amount charged	The amount being charged for the services provided.	This is a required field.
Quantity	The number of units.	This is a required field.
Remove this Section	Use this to delete a section on this page.

Add any CPT Sections or click Save.

Add CPT sections

Use Add CPT Section to add additional CPT codes to a claim.

Remove a section

Use this command to remove a section from a claim. Use it, for example, if you accidentally enter one CPT code twice on the same claim.

Submit a claim

To submit a claim:

Click Submit Claim.

The system assigns a unique transaction control number (TCN) to the incoming claim. This number identifies all items in the claim as part of a single claim

When the claim is submitted, the message Client Claim information has been submitted successfully! appears.

Edit a claim

Original claims (not voids or resubmits) may be edited if originated from the Web, but not using an 837 electronic submission.

Check Claim Status

After a billing cycle is run by the state, each TCN will be labeled with its current status in the system. Billing cyckes run every two weeks. When the billing cycle runs, the Web Data System is off-line for the duration of the cycle (usually about one hour). Billing cycles are scheduled to run during off-peak hours.

To check claim status:

On the main menu, click Claims.

The Claims opening screen appears.

Find the record for the client for whom you provided a service by clicking either Client Search or TCN Search on the Actions menu.

You can search by client information or by transaction control number (TCN).

Use the folowing table to interpret the status code associated with each claim (TCN).

Code	Description	Notes
PA	Processed, all CPTs have been paid	The system processed this claim, found that the items on the claim are acceptable (meet the built-in business rules) and scheduled them for payment.
PE	Pending; Claim not yet processed	Claims submitted but not yet processed by the system have this status code.
PN	Processed, no CPTs paid; all denied	The system processed the claim, found that none of the items on the claim are acceptable (meet the built-in business rules) and therefore denied the claim. View the EOB report and then look up the error codes to determine why the items were denied. For information about the error codes, see Explanation of Benefits: Error List.
PS	Processed, some CPTs have been paid	The system processed this claim, found multiple items, determined that some of the items on the claim are acceptable (meet the built-in business rules) and scheduled them for payment; other items did not meet the applicable business rules and were denied. View the EOB report and then look up the error codes to determine why the items were denied. For information about the error codes, see Explanation of Benefits: Error List.
VO	Voided	The system determined that the claim is a duplicate and has voided it. No items will be paid.

Claims processing

A unique transaction control number (TCN) is assigned to each incoming claim. This number is designed to identify all related claim items as part of a single claim.

TCN format

The following table describes the TCN format used by the Web Data System. Note that this is a standard format used by many medical billing programs.

Position	Description	Notes
Position 1-8	Date expressed as CCYYMMDD
Position 9-17	9-digit sequence number
Position 18	Media (how claim was submitted)	0 = Web site 1 = Electronic File
Position 19	Claim type	0 = Original 1 = Void (reversal) 2 = Adjustment (replacement)

Adjudicating claims

All claims submitted are processed as a group of claim items.

For instance, claims submitted with four items (four CPTs) have four claim items that are processed as a single claim. The claim items are assigned a single TCN during the claim adjudication process.

Processing adjustments and voiding paid documents

To adjust one item in a claim with multiple items:

To adjust one item in a claim containing more than one item, you must re-enter all items, even those that do not need to be modified.

Re-enter the unchanged items exactly as they were when first submitted.
Enter the item to be adjusted with the appropriately modified information.

The system processes the adjusted claim as follows:

The claim TCN is reversed (or voided).
The modified item is adjudicated (replaced) and assigned a new TCN.
The other items would are changed, re-adjudicated and assigned the same TCN as the item that was modified.

If you do not include all four items, then the system processes the claim this way.

The original claim TCN is reversed (or voided).
The newly submitted items are adjudicated.

note The items not included in the modified claim are voided, and that will be their final status. To claim these items subsequently, you must submit them as items in a new claim.

To adjust all items in a claim:

The adjustment process similar to adjusting only one item in a claim, however, each item is adjusted. The system processes the claim as follows:

The claim is reversed (voided).
Each item is replaced and assigned a new TCN.

note All items need to be included when adjusting a claim or items that are not included will need to be resubmitted as items in a new claim.

To void one item of a multiple item claim:

To void one item in a claim with more than one item, submit an adjustment instead of a void (see above).

Simply create an adjustment and omit the item you want to void.

To void an entire claim:

To void an entire claim (all items), submit a void. All items are marked as voids.

note Claims for which all the items were denied are not available to be voided.

EOB/Billing Report

Client Claims

Explanation of Benefits: Error List

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Related Topics

EOB/Billing Report

Client Claims

Explanation of Benefits: Error List