March 02, 2016
Area(s) of Interest: Commercial Payors Payor Issues and Reimbursement
In early February, the California Medical Association (CMA) began receiving calls from physicians who reported that the explanation of benefits (EOBs) they were receiving from Blue Shield of California were missing the EOB reason codes that explain the specific reasons why a plan denies, adjusts or contests a claim.
CMA escalated the issue to Blue Shield and learned that the lack of information on the EOBs was the result of a system issue that affects PPO claims processed beginning January 1, 2016, to present. The EOBs are also missing information regarding the availability of the provider dispute resolution mechanism and the procedure for filing a dispute.
Payment on claims was not affected as checks were issued with the EOBs; however, without the EOB reason code information it is impossible for practices to identify why the PPO claim was denied, adjusted or contested.
Blue Shield originally attempted to implement a system fix in mid-February; however, problems with the testing pushed the fix date into March. Blue Shield reports it is in the process of testing again and is targeting March 9, 2016, for implementation of the fix.
Once the system fix is in place, Blue Shield has advised it will issue corrected EOBs on all affected claims. CMA is working with Blue Shield to ensure that physicians have 365 days from the date of the corrected EOBs in which to appeal any claims.
CMA will continue to monitor the issue closely and post updates as they are available.