Provider Administrative Policy
Our provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts.
Blue Cross of Idaho works diligently on behalf of our members to develop contracting relationships with Idaho dental providers and Blue Cross Blue Shield dental affiliates (national Dental Grid).
Blue Cross of Idaho complies with the prompt pay bill enacted in 2004 by the state of Idaho (Title 41; Chapter 56).
1. Submission requirements by Practioner or Facility:
A. For paper claims submitted within 45 days of the date of service, Blue Cross of Idaho has 45 days to process and issue the result or interest will begin to accrue if the claim qualifies. The definition for "submission of claim" is the date the claim is sent as indicated by the mail stamp on the envelope.
B. For electronic claims submitted within 30 days of the date of service, we have 30 days to process and issue the result or interest will begin to accrue if the claim qualifies. The definition for "submission of claim' is the date an electronic claim is transmitted to Blue Cross of Idaho from a clearinghouse, including our own clearinghouse.
2. Payment requirements:
A. For paper payments, the definition for "date of payment" is the date the payment is issued by Blue Cross of Idaho as indicated by the mail stamp on the envelope.
B. For electronic payment, the "date of payment' is the date we issue an order to provider's bank.
3. Certain exceptions are allowed under the law if one of the following applies:
A. Reasonable medical records requests are made.
B. Accident report(s) requests are required for the purpose of subrogation.
C. Blue Cross is required to coordinate benefits.
D. If the fee or premium for benefits has not been paid to Blue Cross of Idaho.
E. Claims involving suspected fraud.
F. If we cannot comply due to an act of God, bankruptcy, strike, labor dispute or act of terrorism.
4. Certain benefit plans are also excluded from the law.
- For example, the law does not apply to claims related to Medicare Advantage, Medicare supplement, the Federal Employee Program (FEP) or nonrenewable short-term coverage issued for a period of 12 months or less. In particular, this includes the following exceptions: policies or certificates of insurance for specific disease, hospital confinement indemnity, accident-only, credit, Medicare supplement, disability income insurance, student health benefits only coverage issued as a supplement to liability insurance, worker's compensation or similar insurance, automobile medical payment insurance or nonrenewable short-term coverage issued for a period of twelve (12) months or less.
5. Interest rates change yearly and are paid at the statutory rate pursuant to section 28-22-104, Idaho Code:
A. We base interest amounts on the amount we paid on the claim.
B. Interest is not due on claims where no payment is made.
C. Interest payments are not required if less than $4.00 per claim.
D. We may issue interest payments separately from claims payments.
E. Interest shall accrue from the date payment was due until the claim is paid. Date of payment is the date Blue Cross of Idaho sends payment to the provider.
F. If the date of receipt and the date of payment cover two different interest rate periods, we will use the rate in effect on the date we receive the claim.
The following explains how Blue Cross of Idaho will issue interest payments:
- If interest is due, we will send a quarterly report to identify claims that may require payment.
- The report will include all claims that are eligible for interest due from the date received to the date paid as stated above.
- Claims where no payment was paid will not be included (such as deductible, non-covered, etc.)
- If the report identifies interest due, a check will be sent with the report. The report will be mailed by the end of the month following the quarter.
- If a non-contracting provider submitted the claim resulting in payment to the member, any interest due will be paid to the member.
Any interest paid will be reported to the Internal Revenue Service.