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Key Takeaways

• Every month, BlueCross receives an average of 4.7 million claims on behalf of our 3.4 million members.
• Processing a claim means verifying the member’s policy covers the services provided and that those services are supported by our medical policy standards.
• We process around 84 percent of claims within a day by our electronic system and require no additional information.
• Our claims processing team reviews delayed claims and typically resolves them quickly.

Have you ever wondered what happens from the time you leave your doctor’s office until you’re informed how much you owe and how much your health plan will cover? This primer on how claims are created and our process for resolving them will get you up to speed quickly.

The best part? You won’t be quizzed.

The fundamentals

For many members, apprehension is common due to the misconception that there will be hassle, a large expense or jargon-filled paperwork to deal with. At BlueCross, we have taken steps to ensure that our claims process runs smoothly, quickly, and with as little work for you as possible.

Think of a claim as an invoice that a health provider (a doctor, hospital or clinic) provides to your health insurer to review based on the benefits included in your plan.

The claim-creation process involves two steps:

1. You receive medical services.
2. Your doctor creates and submits a document – the actual claim – to determine how much your health insurer will pay and how much you will pay (based on your plan details).

The claim outlines the medical services you received using specific medical codes (known as current procedural terminology, or CPT, codes) which we review and process electronically.

About 98 percent of claims we receive are in an electronic format. We accept paper claims by mail or fax, which are scanned and converted into an electronic document.

“Most claims involve a basic set-up, which begins with a member receiving medical services, a claim getting submitted and us receiving it,” says Maria Darras, vice president of commercial operations at BlueCross. “Our automated claims system interprets the data and either processes it immediately, meaning no one needs to touch it and both the provider and member are updated on how much the policy will pay, or marks it for further attention. This requires a claims processor to step in and find out what the system is asking for.”

Our processing system was implemented to increase speed, efficiency and convenience. We regularly update our internal checks and balances to ensure we meet high standards for what members like you value most – like how accurately we’re processing claims, promptly processing payment, answering phone calls and resolving issues on your behalf.

Acing the exam

We process large volumes of claims every day, and our member satisfaction and rapid claim resolution reflect our commitment to high-quality service. According to Maria, BlueCross processes an average of 4.7 million claims a month  across all lines of business, including commercial, BlueCare and senior care plans, with an average 84 percent going through on their first pass.

Around 99 percent of all claims BlueCross receives are processed within 30 days.

It’s important to note that these are not arbitrary decisions. We compare the service you requested or received against these criteria:

• the details of your health plan, which you can find in your “evidence of coverage”
• your benefits structure and where you stand on your deductible and out-of-pocket maximums at that point in time
• our medical policy standards, which are designed to cover evidence-based treatments

Our goal is make sure that if your plan covers something, we’re paying our share on your behalf. 

“We’ve made this electronic configuration as seamless as possible, to the point a member’s claim overwhelmingly is processed automatically and there’s little need for someone to manually work on it,” Maria says. “We’re always looking for opportunities to provide better service for our members, and we’ve implemented process improvements over the years. If we can understand why claims are marked in our system we can determine how to keep them moving. We ask, ‘What’s missing? Is it system configuration? Is it data coming in? Is there a need for medical review that goes beyond the scope of our system?’”

The customer service team that addresses these questions includes claims processors, who are intently focused on that 16 percent of claims that don’t go through automatically. These claims are often just making an unintended pit stop, where a processor works to correct simple errors like a misspelled name or an invalid CPT code. These “stops” can sometimes require a processor to request medical records from a provider to ensure certain criteria are met to keep the claim moving.

After that, the member will receive an explanation of benefits (EOB) that details the total cost associated with that claim – specifically, the amount of the medical service, the amount paid to the provider by BlueCross on your behalf, and the amount you owe to the provider. (What we cover – and what you pay – is based on substantial discounts we negotiate with providers on your behalf.)

If there are issues with payment due or the EOB is unclear, please call our customer service team.

Advanced studies

Though BlueCross has taken steps to ensure claims are processed promptly, no two claims are exactly alike, and there can be hiccups. Delayed claims are usually resolved quickly, but there are instances where a claim can be denied. Common reasons include:

• Non-covered service. We recognize that this is a complicated area of our health plans, and there are difficult decisions we have to make when setting our medical policy. Our guiding principles are to cover broadly supported practices that will lead to better health for all of our members. And because we want to keep premiums as low as possible, it’s our responsibility to ensure we aren’t paying for services that aren’t covered.
• Referral/pre-authorization required. Some non-emergency services require a doctor receive written approval from a health insurer before moving forward with a procedure for it to be covered.
• Transcription errors. While they more often result in a delayed claim, misspelled member names and birthdates, invalid codes and missing subscriber numbers sometimes prompt a denial.

A denial isn’t necessarily the end of the story. A member can file a grievance for a denied claim. During this process, a committee made up of BlueCross representatives from benefits administration, legal counsel and other departments revisits the claim, along with any additional materials submitted by the member. This review process will be the subject of a future article on Insights.

“A claim isn’t often denied, but when that happens, we will work with the member to investigate the issue,” Maria says. “While our advances in technology have made so much of what we do smoother and more efficient for members, we also recognize the time and place for a group of people to become actively involved and carefully consider the unexpected factors and scenarios that arise and directly affect members’ lives.”

Summary review

Now that you’ve learned about the path of a standard medical claim, remember:

• BlueCross processes an average of 99 percent of claims within 30 days of receipt.
• Of those claims, 84 percent are approved by our electronic processing system on first pass.
• Processing a claim means comparing the service to a member’s policy details and our medical policy standards.

For claims that are flagged in our system, we have a hands-on team in place ready to work on your behalf to resolve issues.