Please note, this communication applies to Healthy Blue + MedicareSM (HMO D-SNP) offered by Blue Cross and Blue Shield of North Carolina (Blue Cross NC).

Availity serves as our electronic data interchange (EDI) partner for all electronic data and transactions. The Availity EDI processing generates response files for each submitted electronic file and delivers them to the submitter’s Availity mailbox. It is important to review these responses to understand where your claims are in the process.

Electronic file submitter

• If your organization uses a clearinghouse or vendor, they have an Availity mailbox to submit clients’ files. Availity delivers the responses for claims to the same mailbox, and the clearinghouse or vendor is responsible for returning the results to their clients and resubmitting any files rejected for formatting, interchange, or transaction set errors. The submitter in this scenario is the clearinghouse or vendor.
• If your organization uses a practice management software, an Availity mailbox is set up during initial registration for your electronic file submissions. The submitter is your organization and is responsible for analyzing the responses to verify there are not any file errors or claim rejections that require correction and resubmission within timely filing guidelines.

Availity electronic file process

1. Submit electronic file to Availity — Availity validates for file format and returns file acknowledgments to the submitter’s Availity mailbox. If there are any edits at this point, the entire electronic file will not advance and will require resubmission within timely filing guidelines.

2. HIPAA and payer specific edits — The electronic file moves to the next phase, which is HIPAA and business editing. Examples include

• Valid subscriber ID for the date of service for the date of service
• Billing and coding validation                                             

If an error occurs at this point, the individual claims with the errors must be corrected, resubmitted as an original claim and do not advance. The claims that do not have an edit will then route to the adjudication systems for second-level edit validation.

3. Blue Cross NC payer receives electronic file from Availity — For the Medicaid Medicare line of business, there is a second level of editing.

Edits for this second level return the Delayed Payer Report (DPR). Only claims that pass will advance for adjudication and will be displayed using Availity claim status, electronic claim status transactions, Availity remittance inquiry, 835 electronic remittance advice, and paper Explanation of Payment. If there are edits, the claim requires resubmission within timely filing guidelines.

Electronic responses

File acknowledgment - Indicates whether we receive an electronic file in the correct format and acceptance by Availity.

• Action required - If any errors occur at this stage, the submitter will need to correct and resubmit the entire electronic file to Availity.

Immediate Batch Response (IBR) - This report acknowledges accepted claims and identifies claim edits due to HIPAA and business edits. The report also includes claim counts and charges for the electronic file. Availity creates this file prior to routing accepted claims to the adjudication systems.

• Action required for claims with edits: Rejected claims require resubmission within timely filing guidelines and will not advance to the adjudication system that would display Availity claim status, electronic claim status transactions, Availity remittance inquiry, 835 electronic remittance advice, and paper Explanation of Payment. Not applicable to denied claims.

Delayed Payer Report (DPR) - This report is currently only returned for the Medicare line of business and contains second-level editing from the adjudication system after Availity has routed claims that passed on the IBR report.

• Action required for claims with edits: Rejected claims would need to be resubmitted and will not display on Availity claim status, electronic claim status transactions, Availity remittance inquiry, 835 electronic remittance advice and paper Explanation of Payment.

What if I need assistance?

If you have questions about this communication or need assistance with any other item, contact your local Provider Experience representative or call Provider Services at 833-540-2106 or Availity Client Services with any questions at 800-AVAILITY (282-4548).

For more information, visit Healthy Blue + Medicare.