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For Health Professionals

Provider Automation

Ways to simplify your transactions with Capital BlueCross

Capital BlueCross has a strong commitment to automation. Provider Automation offers the provider, clearinghouse and vendor community’s experiential knowledge and support to guide our partners to appropriate electronic solutions. We provide multiple methods of electronic claims submission. We fully support ANSI HIPAA compliant version 5010 transaction submission. We also fulfill your online needs with our secure online gateway, NaviNet®. NaviNet® is an independent company providing this provider portal service on behalf of Capital BlueCross.

General Information

Capital BlueCross supports all ANSI HIPAA compliant version 5010 transactions, including:

  • ANSI 835 ERA (Electronic Remittance Advice)
  • ANSI 837 Institutional Claims
  • ANSI 837 Professional Claims
  • ANSI 270/271 (Eligibility and Benefit Request)
  • ANSI 276/277 (Claim Status Inquiry)
  • ANSI 278 (Health Care Services Review - Request for Review and Response)

Authorization Process

Prior to sending Electronic Data Interchange (EDI) transactions to Capital BlueCross, a trading partner relationship must be established that will define a legal relationship and requirements for the exchange of EDI transactions. Please refer to the contact information section to begin the process of establishing a trading partner relationship.

Contact Information

Use these contacts to become authorized to coordinate testing of EDI transactions, send EDI transactions, and submit questions about the Capital BlueCross User Guide or the HIPAA Implementation Guides.

Provider Automation
Telephone: 800.874.8433, option 4
Email: Provider.Automation@capbluecross.com
Hours of Operation: 7:30 a.m. to 4:30 p.m.

Capital BlueCross (CBC) Support Center
Telephone: 717.541.7200
Hours of Operation: 24 hours a day, seven days a week

Even though a problem may be reported 24 hours a day, seven days a week, the problem may not actually be resolved until the next normal business day.

System Operating Hours

Monday through Saturday (24x6). Generally available on Sunday’s with potential outages due to system maintenance.

Holiday Schedule – Capital BlueCross offices are closed on these days and technical issues reported to the Capital BlueCross Support Center may not be addressed until the next business day.

  • New Year’s Day
  • Memorial Day
  • Independence Day
  • Labor Day
  • Thanksgiving Day and the day after
  • Christmas (includes Christmas Day and either the day before or after)

Notification Process

When systems may be unavailable outside of regularly scheduled maintenance due to technical issues, Provider Automation will notify providers and trading partners via email. It is important for Trading Partners to supply appropriate contact information to Provider Automation during the enrollment process and to update Provider Automation on any changes in contact information.

ANSI 835 ERA (Electronic Remittance Advice)

Capital BlueCross is able to provide weekly electronic remittance information regarding claim adjudication and payment using the ANSI X12 835 transaction. Providers may be able to use this remittance information as input to automatically update their patient accounts receivables if their practice management system is capable to processing an 835 transaction. In order to get started with the electronic remittance advice, please complete and submit the enrollment form below.

Electronic Claims Submission

Electronic submission of claims is widely acknowledged to afford a broad range of benefits including:

  • Improved administrative efficiencies
  • Reduction in cost of submitting claims
  • Reduction in manual processing errors and delays
  • Improved payment turnaround time

Capital BlueCross offers multiple methods of electronic submission:

EDI Direct

With EDI Direct, participating providers have the ability to submit HIPAA compliant files directly to Capital BlueCross. Upon completing a Trading Partner Agreement with Capital BlueCross, a testing process ensures the file meets HIPAA and Capital BlueCross requirements for successful transmission to our adjudication system.

For more information, please contact us toll-free at 800.874.8433 and ask for Provider Automation or e-mail us.

Direct Data Entry

Capital BlueCross offers Direct Data Entry (DDE), an online service that enables submission of CMS 1500 claims directly to Capital BlueCross via secure Internet lines. A printable confirmation is displayed once a claim is submitted, and an accept/reject report that identifies whether the claim has been accepted or rejected is available the next business day.

To use the DDE claims entry option, providers must be registered with our secure online gateway, NaviNet®. NaviNet® is an independent company providing this provider portal service on behalf of Capital BlueCross. To determine if our DDE service would meet your needs or if you are interested in DDE, please call 800.874.8433 and ask for Provider Automation or e-mail us.

Clearinghouses

If neither direct method suits your needs, you may want to utilize a clearinghouse. Capital BlueCross can receive EDI claims through a clearinghouse and submission of ANSI ASC X 12N current HIPAA compliant version.

Real Time Eligibility & Benefit and Claim Status Inquiries

Capital BlueCross accepts ANSI HIPAA compliant version 5010 270 eligibility inquiry real time requests which include a single inquiry or submission (one eligibility inquiry to one information source for one patient).The response from Capital BlueCross as the message receiver is either an error response or the corresponding X12 message response (TA1, 999 or 271).

Capital BlueCross also accepts ANSI HIPAA compliant version 5010 276 claims status inquiry real time requests which include a single inquiry or submission (one eligibility inquiry to one information source for one patient).The response from CBC as the message receiver is either an error response or the corresponding X12 message response (TA1, 999 or 277).

Capital BlueCross also accepts ANSI HIPAA compliant version 5010 278 Health Care Services Review — Request for Review and Response real time requests which include a single inquiry or submission (one request to one information source for one patient). The response from CBC as the message receiver is either an error response or the corresponding X12 message response (TA1, 999 or 278).

These transactions may be submitted directly to Capital BlueCross or through a clearinghouse or vendor arrangement.

Trading partner should send no more than one transaction per 2 seconds with 5 concurrent transactions, to ensure that optimal throughput is maintained.

Capital BlueCross maintains a System availability of no less than 86 percent of the time per calendar week for both real time processing. Capital BlueCross adheres to a maximum response time between each trading partner of 4 seconds or less per hop with a total round trip of 20 seconds or less.

Real-Time Connectivity Options

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