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PAP801

BlueCard® Claims Submission


Provider Administrative Policy

Section
BlueCard
Policy Date
February 2008
Status/Date
Revised/March 2015
Provider Type(s)
All Providers  

Disclaimer

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


Policy

BlueCard® Claims Submission

You can identify BlueCard claims by the PPO suitcase logo  PPO suitcase logo  on the member’s ID card.

You can identify Medicare Advantage claims by the MA PPO logo  on the members ID card.

Member ID cards that do not have the PPO or blank suitcase logo suitcase logo  should contain information on how to submit claims to the member’s home plan. Here are some ideas to keep in mind when submitting out-of-area claims:

  1. Submit all out-of-area Blue Cross Blue Shield claims through the local Blue Cross Blue Shield plan.
  2. Providers who contract with both Blue Cross of Idaho and Regence BlueShield of Idaho may submit BlueCard claims to either plan unless the patient is a member of a national account.
  3. If you contract with Blue Cross of Idaho or Regence BlueShield of Idaho, you must send the BlueCard claim to the plan you contract with. Failure to do this could result in incorrect benefits and payment to the subscriber.
  4. You must submit some prefixes only to Blue Cross of Idaho or to Regence BlueShield of Idaho. We now offer a Blue Card alpha prefix lookup on bcidaho.com/providers. This will assist you in identifying, where to send the claim(s) for processing. If you are billing claims electronically to Blue Cross of Idaho, the claims will "error out" for resubmission to Regence BlueShield. If you are billing hard copy, we will return the claim for you to resubmit to Regence BlueShield.
  5. If you do not contract with either plan, you may submit BlueCard claims to either plan.
Ancillary Provider Claim Filing Instructions
Ancillary providers are independent clinical laboratory (Lab), durable/home medical equipment and supplies (DME) and specialty pharmacy providers. The local plan, as defined for ancillary services, is the service area the ancillary services are rendered.
  1. Independent clinical laboratory providers are required to file claims to the local plan in the same state where the specimen was collected. Exception:  For Blue Cross of Idaho members, if the referring physician is located in a contiguous county and the rendering provider is contracting with Blue Cross of Idaho and processed in-network.
  2. DME providers are required to file claims to the local plan of the state where the member receives the equipment or supply. Exception:  For Blue Cross of Idaho members, if the equipment or supply is purchased in a contiguous county or shipped to a contiguous county and the rendering provider is contracting with Blue Cross of Idaho the claim should be filed direct to Blue Cross of Idaho the claim should be filed direct to Blue Cross of Idaho and processed in-network.
  3. Specialty pharmacy providers/suppliers are required to file claims to the local plan where the ordering physician is located. Exception:  For Blue Cross of Idaho members, if the ordering physician is located in a contiguous county and the rendering provider is contracting with Blue Cross of Idaho the claim should be filed direct to Blue Cross of Idaho and processed in-network.

Independent Clinical Laboratory

Provider type

Any type of non-hospital based laboratory

Types of service include, but are not limited to: blood, urine, samples, analysis, etc.

Where to file File the claim to the plan in the state where the specimen was drawn.  We determine the state by the location of the referring physician. 
Example

Blood is drawn in a laboratory or office setting located in Boise, Idaho. Blood analysis is done in California. File to: Blue Cross of Idaho.

*Claims for the analysis of a lab draw specimen must be filed to the plan where the specimen was drawn.
*
Claims filed with a place of service (POS) 81 will follow the ancillary claims filing instructions in this policy. All other POS (including 11, 21) will follow standard Bluecard filing procedures.

In General:

Lab draws the specimen and processes:  the lab submits claim with POS 81

Physician draws and lab processes the specimen:   submit claim with POS 11

Hospital/Facility draws and lab processes the specimen:  submit claim with POS 21

Durable/Home Medical Equipment and Supplies

Provider type Types of services include, but are not limited to: hospital beds, oxygen tanks, crutches, home infusion, etc.
Where to file File the claim to the plan where the equipment was shipped to or purchased in a retail store.
Example
  1. Wheelchair is purchased at a retail store in California. File to: Blue Cross and Blue Shield of California.
  2. Wheelchair is purchased on the internet from an online retail supplier in California and shipped to Idaho. File to: Blue Cross of Idaho.
  3. Wheelchair is purchased at a retail store in Utah and shipped to Idaho. File to: Blue Cross of Idaho.
  4. Pharmacy injectable is shipped to a physician's office located in Idaho for administration by the physician. File to: Blue Cross of Idaho.
  5. Pharmacy injectable is shipped to a patient's home in Idaho for administration in the patient's home by a home infusion provider or subcontracted home health nurse. File to: Blue Cross of Idaho.

Specialty Pharmacy

Provider type Types of service - (High dollar, non-routine, biological therapeutics ordered by a healthcare professional as a covered medical benefit as defined by the member's Plan's specialty pharmacy formulary): include, but are not limited to: injectable, infusion therapies, etc.
Where to file File the claim to the plan where the ordering physician is located.
Example

Patient is seen by a physician in Utah who orders a specialty pharmacy injectable for this patient. Patient will receive the injections in Idaho where the member lives for six months of the year. File to: Blue Cross Blue Shield of Utah.

*Note:  Blue Cross of Idaho does not currently have specialty pharmacy provider types. This rule will not apply to any claims billing to Blue Cross of Idaho.

IMPORTANT NOTES:

Virtual radiology providers - submit claims to the local state plan where the reading or professional component is performed.

Ambulance/Air Ambulance Providers - Please refer to PAP354, Independent Air/Ground Ambulance Billing for filing instructions.

Filing tips for border county/state providers - Providers that contract with multiple Blue Cross Blue Shield plans in more than one state may find the following information helpful.

Border county providers - For providers that practice in border areas (contiguous counties), the standard rule is to always file the claim to the plan located in the state where you provided the service.

Exceptions - When the membership is held by a bordering Blue plan you contract with and the member lives in the state where the member's home plan is located, file the claim directly to the bordering blue Plan (member's home plan).

FEP - The updated guidelines do not apply to claims submitted for Federal Employee Program (FEP) members. You should continue to follow FEP claims filing guidelines.

Implementation - Blue Cross of Idaho implemented these guidelines in October 2012, and intended to help standardize claim-filing procedures, regardless of your location. All Blue Plans were mandated by the Blue Cross Blue Shield Association to implement these changes by October 14, 2012.

Ancillary claim filing rules - Apply regardless of the provider's contracting status with the Blue Plan where the claim is filed. See exceptions noted above.

Eligibility & contracting status - Providers are strongly encouraged to verify member eligibility and benefits by contacting the phone number on the back of the member card prior to providing any ancillary service. Providers that utilize outside vendors to provide services (e.g., sending blood specimen for special analysis that cannot be done by the laboratory where the specimen was drawn) should utilize in-network participating ancillary providers to reduce the possibility of additional member liability for covered benefits. Members are financially liable for ancillary services not covered under their benefit plan. It is the provider's responsibility to request payment directly from the member for non-covered services.  

Please contact your local plan if you have additional questions.


Policy History

Date Action Reason
March 2015 Revised Added ACF exceptions
May 2013 Revised Added Ambulance/Air Ambulance
November 2012 Revised Clarified Independent Clinical Laboratory Where to File
October 2012 Revised Updated language for Border County Providers
July 2012 Revised Revised Ancillary Provider Claim Filing Instructions
June 2012 Revised Revised Exceptions: section to clarify process
November 2010 Revised Ancillary provider information added
April 2010 Revised Medicare Advantage Secure Blue PPO suitcase added
October 2009 Revised New language added
May 2008 Revised Title change

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