Dispute
A dispute is usually a request to reconsider a claim that has been denied, adjusted (paid at less than billed charges), or contested. Providers may also dispute billing determinations, such as procedure codes, allowances, and the bundling and unbundling of claims; administrative policies, procedures, and terminations; reimbursement requests for overpayments; and any contract issues.
Dispute determination date
The date Blue Shield's determination in response to a dispute is electronically submitted or deposited in the U.S. mail.
Bundled dispute
A group of substantially similar claims that are individually numbered using the Blue Shield assigned Internal Control Number (ICN) to identify each claim contained in the bundled dispute.
Also, a group of substantially similar contractual disputes that are individually numbered using the section of the contract and sequential numbers that are cross-referenced to a document or spreadsheet.
Date of contest, denial, notice, or payment
The date Blue Shield's claim decision, or payment, is electronically transmitted (835) or deposited in the U.S. mail (Explanation of Benefits).
Good cause for untimely submission of claims
Circumstances reasonably beyond the control of the provider that prevent the timely submission of a claim are considered "good cause".
Examples of circumstances beyond the control of the provider, include, but are not limited to:
- Patient gives incorrect health coverage/insurance information (copy of an incorrect ID card)
- Patient is unable to provide health coverage/insurance information (patient is comatose or passes away before the information can be obtained)
- Natural disaster/acts of nature (fire, flood, earthquake, etc.)
- System-wide loss of computer data (system crash)
Examples of circumstances that don’t constitute "good cause":
- Claim is sent to the wrong carrier (Blue Cross instead of Blue Shield), but the provider has the correct health coverage/insurance information
- The claim is submitted in timely fashion, but Blue Shield is unable to process because the claim is incomplete (doesn’t contain the minimum data elements to enter the claim into the system, i.e., missing subscriber number)
- Providers have an obligation to be responsible for appropriate timely billing practices.
- Requests to review a claim timely filing denial because the provider believes they have good cause for the delay will be handled as a dispute.
Provider inquiry
A request for information regarding claim status, member eligibility, payment methodology rules (ClaimCheck logic, bundling/unbundling logic, multiple surgery rules), Medical Policy, coordination of benefits or third-party liability/workers compensation issues. Inquiries include submission of corrected claims.
Receipt date
The working date when a dispute is submitted online or delivered to the designated provider dispute post office box.
Unfair billing pattern
Engaging in a demonstrable and unjust pattern of bundling and unbundling or up-coding of claims, and/or other demonstrable and unjustified billing patterns.
Unjust or unfair payment pattern
Any practice, policy, or procedure that results in repeated delays in the processing and/or correct reimbursement of claims as defined by applicable regulations.
