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Pacific Blue Cross - Submitting Claims Through the PROVIDERnet Integration

Now that you have your Jane account integrated with Pacific Blue Cross, you’re ready to begin submitting claims - YAY!

If you’ve been previously tracking your Pacific Blue Cross claims in Jane, but submitting them through the PROVIDERnet portal outside of Jane, below are the steps to take to transition existing patient claims

If you’re brand new to submitting to Pacific Blue Cross, you can skip past this portion about transitioning claims.

Transitioning Patient Claims

Your previous Pacific Blue Cross insurer and patient claims are not compatible with the integration, so each patient with a current Pacific Blue Cross claim will need a brand new claim set up using the Pacific Blue Cross PROVIDERnet insurer. You will also want to remove old claims from a patient’s upcoming appointments so that you can replace it with the new claims. Current claims under your previous Pacific Blue Cross insurer can be edited and closed - even if a claim is closed, you can still receive any outstanding payments at a later date.

Creating a Pacific Blue Cross PROVIDERnet Claim

From your main schedule, if you click onto an appointment, you’ll see an option under Insurance Info to Add Claim

A list of available insurers will pop up for you to select from - here you’ll select Pacific Blue Cross PROVIDERnet.

To look up the PBC member, you’ll want to enter both the Policy Number and Identification Number. We’ve included an image of a typical PBC benefit card so that you can easily reference which number is which.

After entering the required numbers, click the blue button to Lookup Member Number

Below, you should see a list of members covered under that specific plan - select the member that matches the patient that received treatment.

If you accidentally select the wrong member, you can always edit and change that information.

When setting up a PROVIDERnet claim, you will also see a check box that can be used to indicate whether or not a Physician referral is on file. You only need to check this box to indicate that a referral is on file if that is a requirement of the patient’s plan.

If you’re setting up a claim for the first time, you’ll see the check box appear right below where you’re prompted to choose which plan member the claim belongs to.

If you’ve previously set up a claim for a patient, but a Physician referral is required in order to submit, you can now edit the claim and indicate below where the plan member is listed, that a Physician referral is on file.

Once this box is checked ‘on’, Jane will communicate to PBC that you have the referral on file and the claim should be processed without issue.

It is recommended that when a Physician referral required, that a copy of that referral is scanned and uploaded to the patient’s chart in Jane in the event that PBC requires proof at a later date. For more information on scanning and uploading files to a patient’s chart in Jane click HERE

Within the claim, you no longer need to indicate % Coverage,Eligible Amount or Max Amount - Jane will take care of updating the amount covered for that visit and passing an applicable balance off to the patient as soon as the claim has been successfully submitted and PBC confirms the exact amount paid. When a claim is submitted, Jane will submit the full cost of the appointment which would have been the same if claims were being submitted through the PBC portal.

After saving the claim, you should now see the claim attached to the appointment and you can add the applicable billing code and diagnosis/area treated.

Billing Code - the billing code selected needs to match the duration and type of appointment you’re billing for. So for example, if the patient received a 60 Minute Registered Massage Therapy treatment and it was not the patient’s first appointment, you would want to select 84816.

The necessary Pacific Blue Cross billing codes have been pre-loaded into Jane for you.

Diagnosis - Similar to claims submitted through the Pacific Blue Cross portal, within Jane you are also required to indicate a diagnosis, or rather an area of the body that the patient received treatment on during that visit. In the field for diagnosis, you can simply type the name of the body part that was treated and select the option that best matches. If you’re currently billing claims through MSP/Teleplan, the same diagnostic codes that you’re using to submit Teleplan claims can also be used to submit claims to Pacific Blue Cross.

Your claim should now look similar to this :

And you can arrive the appointment.

Submitting a Pacific Blue Cross PROVIDERnet Claim

Once the appointment is arrived, you should see a Submit button within the claim under Insurance Info.

After clicking the Submit button, you’ll want to review the details for the claim. Again, Jane will submit the full cost of the appointment for you so you should see that amount associated with the invoice.

At the bottom of the page, you’ll need to answer whether or not the claim is related to an Accident, ICBC case, Worksafe BC case or an out of Canada medical emergency. In general, claims that are associated with an accident etc. are not able to be directly submitted to Pacific Blue Cross.

After selecting one of those options, you can click the blue submit button and off your claim goes!

Within a few short seconds, you’ll receive the official claim response and it should look something like this :

Depending on the amount Paid, Jane will adjust the invoices to pass any remaining balance off to the patient and the insurer invoice will also be updated appropriately.

If that all looks good, you can close that window using the X in the top right corner and proceed with collecting any applicable patient payments using the Pay button.

Ta-Da! You’ve now successfully submitted a claim from your Jane account directly to Pacific Blue Cross.

If you’ve chosen to set up your integration to automatically Pay & Approve claims once a response has been received from PBC, you won’t need to do anything further with the claim.

If you’ve chosen to set your integration to leave the claims marked as submitted so that payment can be manually applied, you can refer to this guide document that reviews Receiving an Insurer Payment

In the event that a claim submission was made accidentally and you need to reverse the submission, this can also be done directly from Jane - Reversing Claims through PROVIDERnet