Long Term Care Claims: System Issues and Resolution Updates

Posted November 9, 2017

Blue Cross and Blue Shield of Illinois (BCBSIL) has identified system issues that are causing long term care (LTC) claim rejections and denials. A summary of these issues is included below to provide notification, with expected resolution dates and any action that may be needed on the part of the impacted providers. 

Electronic Claims Submitted via AvailityTM Rejected for Admission Date/Hour and Admitting Diagnosis

The release of new LTC claim system guidelines, as issued by the Illinois Department of Health and Family Services (HFS), made it necessary for all managed care organizations to adjust claim system edits to prevent claims from rejecting for noncompliance. BCBSIL worked with clearinghouses to make the necessary system updates. 

BCBSIL identified an issue with LTC claims (21X, 22X and 65X bill types) that were submitted through Availity from Sept. 19, 2017, through Nov. 1, 2017. The issue was related to the following Health Insurance Portability and Accountability Act of 1996 (HIPAA) edits, which were unintentionally activated during a system release: 

  • 0x3938b7f – Segment DTP (Admission Date/Hour) is used. It may only be used on inpatient claims and some outpatient claims as defined by the National Uniform Billing Committee (NUBC).
  • 0x3938b80 – Segment HI (Admitting Diagnosis) is used. It may be used on most of inpatient claims and some outpatient claims as defined by the NUBC.

Availity relaxed the above edits in their Nov. 1, 2017, off-cycle release. This issue has been resolved and providers should now resubmit claims rejected for these edits.

Claims Incorrectly Routed and Denied for Authorization

Per the HFS guidance, 21X, 22X and 65X are appropriate bill types for LTC claims. Due to an update in authorization logic at BCBSIL, however, all LTC claims submitted with 21X or 22X bill types began routing for authorization validation. Claims may have been incorrectly denied for authorization when an authorization was not required.   

  • BCBSIL will accept all LTC claims that are submitted per the HFS billing requirements. A workaround is currently in place to help prevent additional claims with 21X/22X bill types from routing for authorization.
  • BCBSIL is actively working to isolate all impacted claims and reprocess them according to the patient credit file. No provider action is required; all claims will be reprocessed by BCBSIL.
  • A long-term system fix and all reprocessing of claims impacted by the above issue are targeted for completion by Dec. 31, 2017.

We apologize for any inconvenience the issues referenced above may have caused. Please watch the News and Updates for additional announcements. Information also may be published in our Blue Review provider newsletter.

Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSIL. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Availity. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly.