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Blue Shield experiencing multiple claims processing issues, some delaying payment



March 18, 2016
Area(s) of Interest: Commercial Payors Payor Issues and Reimbursement 

The California Medical Association (CMA) began receiving calls in early February from physicians reporting that the explanation of benefits (EOBs) they were receiving on PPO claims from Blue Shield of California were missing EOB reason codes and information regarding the provider dispute resolution process. Blue Shield reports that only the EOB was affected, not the issuance of payment.


CMA has since learned that there were two other system issues causing delays in payment on a large number of Federal Employee Program (FEP) and out-of-state BlueCard claims.


All three of these issues are related to Blue Shield’s transition to a new claims payment system. The transition began a few years ago, but the final phase of the transition was only recently completed.


Blue Shield reports a system fix was implemented on March 16 for the EOB messaging error. The payor will reprocess affected PPO claims and generate updated EOBs for practices. A timeframe on the completion date of the reprocessing project was not available at the time of publication. A system fix on the BlueCard claim issue was implemented on January 16, and the payor expected to have all affected claims reprocessed, including any applicable interest, by March 18.


Blue Shield reports it is working on correcting the problem affecting delays in issuing of FEP checks on a go-forward basis and will retroactively reprocess all claims automatically to include interest where applicable. Blue Shield did not, however, provide any specific dates for this fix.


Practices do not need to resubmit affected claims.


CMA will continue to monitor this issue closely and will provide updates as they are available.

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