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Update: Medicaid and MMAI Providers: Claims Denial for Incorrect NPI/Taxonomy/COS Information

Posted November 28, 2016 (Updated Dec. 9, 2016)

On Aug. 1, 2016, Blue Cross and Blue Shield of Illinois (BCBSIL) implemented an edit rule to ensure that only compliant claims are available for submission to the Illinois Department of Healthcare and Family Services (HFS). With the implementation of this edit rule, BCBSIL is checking claims to verify the following information is present: 

  • The National Provider Identifier (NPI) or Atypical Provider Identifier (API)
  • A Taxonomy Code
  • The Provider NPI on the claim is registered with HFS
  • The claims dates of service is within the eligibility date range for the NPI registered with HFS
  • The associated Provider Type and Categories of Service (COS) on file are appropriate for the services billed

It has been identified that during the implementation of this new edit rule, certain providers had claims impacted by this edit. BCBSIL anticipates that most newly submitted clean claims filed that were previously impacted will begin to process starting Dec. 16, 2016. Further improvements will be implemented by Jan. 20, 2017, that should resolve any other issues specific to waiver providers.

BCBSIL will be working to adjust claims that were previously impacted by these edits. These adjustments are anticipated to begin on Dec. 28, 2016, with an anticipated completion date of Jan. 30, 2017. It is not necessary for providers to resubmit their claims, unless specifically requested by BCBSIL.

We appreciate your patience as we work to resolve this issue timely. Updates will continue to be published here in the News and Updates section of the provider website.

If you have questions relating to this issue, please contact the appropriate Provider Customer Service line:
MMAI: 877-723-7702

MLTSS: 866-962-9814

ICP: 888-657-1211

FHP: 877-860-2837

Please utilize the following tips to submitting a clean claim:

  1. For electronic claims, confirm use of the correct payer ID of MCDIL. If the correct payer ID is not used the taxonomy may be removed.
  2. Ensure that the taxonomy code appropriate for services delivered on the claims is included on the claim.
  3. Ensure that the NPI used to file claims is registered with HFS via Impact.
  4. Ensure that the provider type and categories of services registered in association with the NPI are appropriate.
  5. Ensure that Approval of Stay is entered for Inpatient claims. Condition Codes must be populated on inbound Institutional In-Patient claims. If Bill Type is 011 and Value Code = 80 Then Condition Codes (Qualifier of BG) C1, C2, or C3 must be present.