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For Health Professionals

Frequently Asked Questions

Health Care Professionals


Provider Relations & Credentialing
How can I become a participating provider?
How can I verify that the information you have for me is up-to-date?
How do I update/change the information that you have on file for me?
How long does the credentialing process generally take?
I have submitted an application to become a participating provider. How can I check the status of my application?
What is the most comprehensive source of information for providers?
Where can I get Capital BlueCross forms that I must use?


Eligibility & Benefits
How can I determine what benefits my patient has?
How can I obtain member eligibility?
How can I tell if my patient has preauthorization requirements?


Reimbursement
I am a professional provider. How can I request reimbursement amounts for CPT codes specific to my specialty?


Claim
Am I able to receive my payments electronically? If so, how?
Am I able to receive my vouchers electronically? If so, how?
How can I check the status of my claim(s)?
How can I send EDI claims to Capital BlueCross?
How do I obtain and interpret my Error (Accept/Reject) Reports?
How do I request access to the Capital BlueCross health plan home page via the NaviNet® portal?
How do I submit an adjustment for a claim I already submitted?
How should I report my provider ID on claims? What about my National Provider Identifier?
Am I able to receive my vouchers electronically? If so, how?

Provider Relations & Credentialing

How can I become a participating provider?

 If you are interested in becoming part of our Provider Network please contact us. Professional Providers may contact us at 800.874.8433 or request information online.  Facility providers may contact 717.541.6500.  We encourage you to join our team of dedicated health care professionals and health care facilities.




How can I verify that the information you have for me is up-to-date?
You may request a copy of your profile by calling your Provider Relations Consultant at 800.874.8433.


How do I update/change the information that you have on file for me?

 To update/change your provider information contact the Provider Service Department at 800.874.8433. In addition, professional providers may complete the Provider Change Notification Form and mail it to us at the address on the bottom of the form.

Providers may also submit changes to their information by accessing the Capital BlueCross health plan home page via the NaviNet® portal.

 

 




How long does the credentialing process generally take?

 The credentialing process is generally completed within 180 days (or sooner), because credentialing information, including but not limited to, application, attestation, and all primary source verification cannot be older than 180 days at the time of the Credentialing Committee decision. 




I have submitted an application to become a participating provider. How can I check the status of my application?
Professional providers may call the Provider Service Department at 800.874.8433.  Facility providers may call 717.541.6500.


What is the most comprehensive source of information for providers?
The most comprehensive source is the Provider Manual.  You can view the Provider Manual on the Capital BlueCross health plan home page via the NaviNetâ portal.  Also, participating providers receive a copy of the Provider Manual on a CD.  If you did not receive a Provider Manual CD, you may request one by contacting your Provider Relations Consultant.


Where can I get Capital BlueCross forms that I must use?
 You may download electronic copies of forms located on the Capital BlueCross health plan home page via the NaviNetâ portal. If you are not a registered user, you may call Provider Services Telephone Unit at 866.688.2242.



Eligibility & Benefits

How can I determine what benefits my patient has?
 Member benefit information can be obtained  by accessing the Capital BlueCross health plan home page via the NaviNetâ portal or by calling 866.688.2242 and selecting Option 1 for professional providers, or 800.753.1276 for facility providers.


How can I obtain member eligibility?

Member eligibility information can be obtained by accessing the Capital BlueCross health plan home page via the NaviNet® portal or by calling 866.688.2242 and selecting Option 1 for professional providers, or 800.753.1276 for facility providers.




How can I tell if my patient has preauthorization requirements?
Member benefit information, including preauthorization requirements, can be obtained  by accessing the Capital BlueCross health plan home page via the NaviNetâ portal or by calling 866.688.2242 and selecting Option 1 for professional providers, or 800.753.1276 for facility providers.

Additionally, providers may determine whether a particular service for a particular member requires preauthorization by calling 800.471.2242 and selecting Option 1.



Reimbursement

I am a professional provider. How can I request reimbursement amounts for CPT codes specific to my specialty?
Standard Fee Schedule information may be obtained by accessing the Fes Schedule feature on the Capital BlueCross health plan home page via the NaviNetâ portal. (Note: Fee Schedules are subject to change).



Claim

Am I able to receive my payments electronically? If so, how?

Yes.  Access the Electronic Funds Transfer page on the Capital BlueCross Web site and follow the instructions. 




Am I able to receive my vouchers electronically? If so, how?
 For information regarding receiving your vouchers electronically, professional providers should call the Provider Service Department at 800.874.8433 and ask for Provider Automation. Facility providers should contact their assigned Provider Automation Consultant.


How can I check the status of my claim(s)?
 Claim status information can be obtained by accessing the Claim Status feature on the Capital BlueCross health plan home page via the NaviNetâ portal or by calling 866.688.2242 and selecting Option 3 for professional provider claims, or 800.753.1276 for facility provider claims.


How can I send EDI claims to Capital BlueCross?

Capital BlueCross can receive EDI claims either through a clearinghouse or through direct submission of ANSI ASC X12N version 5010 Errata. To get a clearer picture of how your electronic claims get to us, view the various steps outlined in the below PDF document.

 


For more information regarding direct claim submission, professional providers please call the Provider Service Department at 800.874.8433 and ask for Provider Automation. Facility providers, contact your assigned Provider Automation Consultant.




How do I obtain and interpret my Error (Accept/Reject) Reports?
EDI Direct submitters automatically receive their Accept/Reject Reports as part of the EDI Direct submission process.  Accept/Reject Reports may also be retrieved using the Accept/Reject Report feature by accessing the Capital BlueCross health plan home page via the NaviNetâ portal. 

Providers who submit claims using the 1500 Claim Form or UB04 Form may also retrieve Accept/Reject Reports using the Accept/Reject Report feature on the Capital BlueCross health plan home page via the NaviNetâ portal. 

Providers who submit claims electronically through a clearinghouse should have access to reports from the clearinghouse that may include error messages for claims that have been unsuccessfully transmitted to Capital BlueCross.  For assistance interpreting these reports, Professional Providers may call 800.874.8433 and ask for Provider Automation or email Provider Automation at provider.automation@capbluecross.com.


How do I request access to the Capital BlueCross health plan home page via the NaviNet® portal?

 You can enroll with NaviNet®at
https://enroll.navimedix.com/enrollment/shared/office-search. Please contact your Provider Relations Consultant or the Capital BlueCross Customer Service Call Center at 866.688.2242 for professional providers and 800.753.1276 for facility and ancillary providers.




How do I submit an adjustment for a claim I already submitted?
Claims submitted electronically may be adjusted using the Adjust Claims feature on the Capital BlueCross health plan home page via the NaviNetâ portal. Claims submitted on paper may be adjusted using the Direct Data Entry feature, but the entire claim must be rekeyed, reflecting the appropriate changes and identifying the claim as an adjustment. Alternatively, claims submitted on paper by Professional Providers may also be adjusted using the paper Professional Provider Claim Adjustment Form available in the Provider Library section of the Capital BlueCross health plan home page via the NaviNetâ portal.


How should I report my provider ID on claims? What about my National Provider Identifier?
Professional Providers using the CMS 1500 (08/05) form:  The group provider ID should be reported in block 33 a.  The individual performing provider ID should be reported in block 24J of the CMS 1500 (08/05) claim form.  Currently, providers may report either their Capital BlueCross group and individual provider ID numbers or may report their NPIs, if they have submitted their NPIs to Capital BlueCross.

Facility Providers using the UB-04 form:  The facility provider ID should be indicated in Locator 56 and the attending provider ID should be indicated in Locator 76, 77, 78 or 79 of the UB-04 form. Currently, providers may report either their Capital BlueCross facility and individual provider ID numbers or may report their NPIs, if they have submitted their NPIs to Capital BlueCross.


Am I able to receive my vouchers electronically? If so, how?
Yes.  Access the Research Claims feature on the Capital BlueCross health plan home page via the NaviNetâ portal to submit payment related questions on particular claims or supply additional information on a claim when payment on the claim has been denied.