Attachment_6_Informational_Requirements_for_Medical_Claims.pdf

Attachment 6 – RFPP05081500001 Informational Requirements for Medical Claims

1. Medical claims shall be transmitted in accordance with regulatory and industry standards for the submission of ANSI 837 transactions. The contractor shall be responsible for maintaining its information system(s) so that it remains compliant with such regulatory and industry standards.

Any system changes that are required by the BOP’s medical claims adjudicator that are not the result of a regulatory or industry-wide change shall be negotiated on a case-by-case basis.

2. Each medical claim, whether submitted electronically or in hard copy , shall identify the inmate by his/her individual BOP inmate register number and shall reflect the patient’s relationship to insured as “self.” The inmate number shall be keyed with five digits, a hyphen, and three digits in the following format: 12345-678. In an electronically transmitted medical claim, this information shall be keyed at 2100BA NM109 for both facility and professional medical claims.

In a UB-04 hardcopy medical claim submission, the BOP inmate register number shall be included in the Cert. - SSN - HIC. - ID NO. field, block 60. In a professional hardcopy medical claim submission, the BOP inmate register number shall be included in the Insured’s I.D.

Number field, block 1a.

3. Each medical claim, whether submitted electronically or in hard copy, shall identify the invoice number under which the individual medical claim is being invoiced. In an electronically transmitted claim, the invoice number shall be referenced in the Patient Account Number field submitted in the 2300 loop, CLM01 segment. In a UB-04 hardcopy medical claim submission, the invoice number shall be included in the Patient Control Number field, block 3a. In a professional hardcopy medical claim submission, the invoice number shall be included in the Patient Account Number Field, block 26. The invoice number shall be limited to 13 characters.

Positions 1-3 will be the institution’s alpha facility code, positions 4-5 will be alpha/numeric and mutually agreed upon by the institution and contractor, and positions 6-13 will be alpha/numeric and sequential. Not all positions, 6-13, must be used. No special characters will be allowed.

4. Medical claims for professional services provided under category , Outpatient Institution

Services – Other Physicians, shall be filed with Place of Service Code 09.

5. Paper medical claims submitted to the medical claims adjudicator shall be mailed or otherwise delivered to the following address:

Mailing:

PGBA/FBOP Medical Adjudication PO Box 870777 Surfside Beach, SC 29587-8777

Physical:

PGBA/FBOP Medical Adjudication 8733 Hwy. 17-ByPass South Surfside Beach, SC 29575