Blue Card Program
Section
About this Manual ....................................................................................... 3
About the BlueCard Program ...................................................................... 3
Products Included in BlueCard Program................................................................... 5
How to Identify Members ............................................................................ 7
Member ID Cards ..................................................................................................... 7
Suitcase Logos ......................................................................................................... 7
BlueCard Eligibility .................................................................................................... 8
Provider Networks for Med Advantage PPO Sharing ................................ 11
ID Cards ................................................................................................... 12
Medicare Advantage Plans ....................................................................... 15
Medicare Advantage PPO Network Sharing Program ............................................ 15
Helpful Hints ........................................................................................................... 15
Authorization Requirements ................................................................................... 16
Claims Process ......................................................................................... 16
Medicare Advantage Claims ..................................................................... 18
Ancillary Claims Filing ............................................................................................. 19
Air Ambulance Claims............................................................................... 20
Medigap Claims ........................................................................................ 21
Claim Processing ............................................................................................. 22
Claim Payment ................................................................................................. 22
Coordination of Benefits............................................................................ 23
Health Information Network ...................................................................... 24
Medical Records ....................................................................................... 26
Provider Appeals ...................................................................................... 27
Frequently Asked Questions ..................................................................... 28
Coordination of Benefits ................................................................................... 30
Prior Authorization/Pre-Certification ................................................................. 31
2
Medical Records............................................................................................... 34
Medical, Benefit, Payment Policy ..................................................................... 35
Claims Payment ............................................................................................... 36
Medicare Crossover ......................................................................................... 37
Medicare Advantage ........................................................................................ 38
Contiguous Counties ........................................................................................ 39
About this Manual
As a Florida Blue participating provider, you may render services to patients who have health care
coverage with another Blue Plan. This manual provides you with BlueCard® Program administrative
guidelines and explains policies, billing and payment processes and requirements. It offers helpful
information about:
•
Identifying members
•
Verifying eligibility
•
Obtaining precertification
•
Filing claims
Note: In the event of any inconsistency between information contained in this Manual and the
agreement(s) between you and Florida Blue, the terms of such Agreement(s) shall govern. Also, please
note that Florida Blue and other Blue Cross and/or Blue Shield plans, may provide available information
concerning an individual’s status, eligibility for benefits, and/or level of benefits. The receipt of such
information shall in no event be deemed to be a promise or a guarantee of payment, nor shall the receipt
of such information be deemed to be a promise or guarantee of eligibility of any such individual to receive
benefits. Further, presentation of Florida Blue identification cards in no way creates, nor serves to verify
an individual’s status or eligibility to receive benefits. In addition, all payments are subject to the terms of
the contract under which the individual is eligible to receive benefits.
About the BlueCard Program
BlueCard is a national program that enables members to obtain health care services while traveling or
living in another Blue Plan’s service area. It applies to all covered inpatient, outpatient and professional
health care services. The program links participating health care providers with Blue Plans across the
country and in more than 200 countries and territories worldwide through a single electronic network for
claims processing and reimbursement.
The program lets you submit claims for patients from other Blue Plans, domestic and international, tous.
We are your sole contact for claims payment, adjustments and issue resolution.
3
The Home Plan is the Blue Plan in the state where the subscriber/member lives, or where the
group/contract is headquartered. Members receive the benefits of their Home Plan contract. The Host
Plan refers to the Blue Plan of the service area away from the member’s home where services are
rendered.
4
Products Included in BlueCard Program
The BlueCard Program applies to a variety of products. Although Florida Blue may not offer all these to
our members, you may see members from other Blue Plans who are enrolled in these other products:
•
Traditional (Indemnity)
•
Preferred Provider Organization (PPO)
•
Exclusive Provider Organization (EPO)
•
Point of Service (POS)
•
Network Blue –Blue Options
•
HMO (Health Maintenance Organization)*
•
Medigap
•
Medicaid (Payment is limited to the member’s Plan’s state Medicaid reimbursement rates. These
ID cards do not have a suitcase logo.)
•
State Children’s Health Insurance Plan (SCHIP) (If administered as part of Medicaid - payment is
limited to the member’s Plan’s state Medicaid reimbursement rates. These ID cards do not have a
suitcase logo. Standalone SCHIP programs will have a suitcase logo.)
•
Standalone vision
•
Standalone prescription drugs
*For HMO members, the BlueCard Program only applies to members traveling outside their Blue Plan’s
service area.
Note: Standalone vision and standalone self-administered prescription drugs programs are eligible to be
processed through BlueCard when such products are not delivered using a vendor. Consult claim filing
instructions on the back of the ID cards.
5
BlueCard Exclusions:
When you provide services to a member who has coverage with another Blue Plan but the BlueCard
Program does not apply, file the claim to Florida Blue as long as the member ID number includes an
alpha prefix. The following products and groups are excluded from the BlueCard Program:
•
•
•
Stand-alone dental
Federal Employee Program (FEP)
Medicare Advantage Plans (HMO, PPO*, PFFS, POS, MSA)
*Exception: Medicare Advantage PPO Network Sharing Program
*Medicare Advantage is a separate program from BlueCard; however, since you might see members with
Medicare Advantage coverage from other Blue Plans, we have included a section on Medicare
Advantage claims processing in this manual.
When you provide services to a member who has coverage with another Blue Plan but the BlueCard
Program does not apply, file the claim to Florida Blue as long as the member ID number includes an
alpha prefix. You may file electronically or send a paper claim.
•
Florida Blue will forward the claim to the member’s Blue Plan for processing and payment. Be
sure to submit the correct alpha prefix.
•
Florida Blue will send a letter advising you that your claim has been forwarded. The remittance
advice and payment may be sent to either the member or the provider.
•
Claim inquiries should be directed to Florida Blue at (800) 727-2227
.
•
When the BlueCard Program does not apply, your contractual agreement with Florida Blue may
not apply. In such cases, you may elect to bill the member upfront.
Alternative Networks/ Alt Net
Although most Blue Card members with the PPO suitcase access the PPC network, there are a few
national accounts that access NetworkBlue. You can identify these BlueCard members by ‘NetworkBlue’
on the front of their ID card and in the Plan Coverage Description field of Availity. The In Network Lab for
NetworkBlue members is Quest Diagnostic and Dermpath Diagnostics. The preferred lab for anatomical
pathology services in Florida is AmeriPath Diagnostics. In the event labs are taken at the provider’s office,
the provider must send the labs to Quest in order for the labs to be covered at the in-network level of
benefits.
•
Call the BlueCard Eligibility line at (800) 676-BLUE (2583). You will be asked for the alpha prefix
on the ID card to be routed to the member’s home plan. You may inquire about:
o Eligibility and benefits.
o Whether the BlueCard Program applies to the member. (There are a few exempt groups.)
o Precertification and referral authorization requirements.
Note: For claim-related information, do not call BlueCard Eligibility; call Florida Blue at (800) 727-2227.
6
How to Identify Members
Member ID Cards
When members of Blue Plans arrive at your office or facility, always ask for their current ID card.
•
A “suitcase” logo on the member’s ID card indicates the BlueCard Program applies.
•
An alpha prefix (3-letter prefix at the beginning of the ID number) identifies the member’s Blue
Plan or national account.
•
The cards include a magnetic strip so providers can swipe the card at the point of service to
collect the member cost sharing amount (i.e., copay, coinsurance, deductible). The funds will be
deducted automatically from the member’s appropriate HRA, HSA or FSA account. Members can
use their card to pay outstanding balances.
•
With health debit cards, members can pay for copayments and other out-of-pocket expenses by
swiping the card though any debit card swipe terminal. The funds will be deducted automatically
from the appropriate member’s HRA, HSA or FSA account.
•
If your office currently accepts credit card payments, there is no additional cost or equipment
necessary. The cost to you is the same as what you pay to swipe any other signature debit card.
Suitcase Logos
A “PPO” inside the logo indicates the member is enrolled in either a PPO or EPO product.
These members use the PPO network for the lowest out-of-pocket costs; in Florida that is
Florida Blue’s PPC network. PPO members may also use the Traditional/PPS/PHS network,
but will usually have higher out-of-pocket costs. Please note, however, that EPO products may
have limited benefits out-of-area. Refer to the member’s ID card for information.
Note: The PPC network is the default BlueCard Host network. If a member is accessing NetworkBlue, the
NetworkBlue name will be on the front of the ID card in the “Blue Product” area.
An empty/blank suitcase logo indicates the member is enrolled in a Traditional, POS or HMO
product. These BlueCard members use the Traditional/PPS/PHS network while in Florida.
Some ID cards do not have a suitcase logo on them. Those are the ID cards for Medicaid, SCHIP, and
Medicare Complementary and Supplemental products, also known as Medigap. Government-determined
reimbursement levels apply to these products. While Florida Blue routes all of these claims to the
member’s Blue Plan, most of the Medicare Complementary or Medigap claims are sent directly from the
Medicare intermediary to the member’s Plan via the established electronic crossover process.
7
BlueCard Eligibility
For Blue Card member eligibility please call (800) 676-2583; this line is for eligibility, benefit and
precertification/referral authorization inquiries only (not claim status).
•
English and Spanish speaking instructions and operators are available to assist you.
•
You will be asked for the 3-letter alpha prefix on the member’s ID card to be routed to the
member’s home plan.
The BlueCard Eligibility line is available 24 hours a day, seven days a week. Many Blue Cross and/or
Blue Shield Plans have automated self-service systems and extended hours. Please keep in mind,
however, that Blue Plans are located throughout the country and may operate on different time
schedules. Also, some do not have self-service capabilities. In these cases, you may need to call back at
a later time.
Because the BlueCard Eligibility line routes to the member’s home plan, if you are calling regarding
several members from different Blue Plans, you will need to call the BlueCard Eligibility line for each
member.
When you verify eligibility and benefits, both electronically and via phone, you will receive the member’s
accumulated benefits. This will help you understand the remaining benefits for the member.
If the cost of services extends beyond the benefit coverage limit, inform the member of any additional
liability
You can also verify eligibility and benefits by using Availity to submit an electronic inquiry.
•
•
•
Submit the complete ID number with alpha prefix; do not include spaces or hyphens.
Hours of operation for other Blue Plans may vary. For Blue Plans that operate in real-time, the
response time typically will be less than one minute.
The following minimum information will be returned: patient name, date of birth, gender,
insurance type code (i.e., PPO, HMO), effective date, coinsurance (in- and out-of-network), copay
and deductible (annual static value only).
Whether additional information is returned depends on the other Blue Plan.
8
Away From Home Care Program (AFHC)
AFHC is a national Blue Cross and Blue Shield Association (BCBSA) out-of-area program available to
certain HMO members. This program enables members to receive Guest Membership benefits from
another participating Blue Plan HMO network while temporarily residing outside their own Plan’s service
area. Members must activate AFHC coverage with their Home Plan by calling the customer service
number indicated on the ID card.
Members have access to a range of benefits, including routine and preventive care services. Guest
members receive the Host’s benefit plan while away from home. When in Florida, the out-of-state Blue
Plan HMO member receives local benefits and a Florida Blue HMO ID card.
Three types of AFHC Guest Membership are available:
•
•
•
Families Apart – available to spouses and dependents living outside the home HMO service area
(annual renewal required).
Students – available to dependents away at school (annual renewal required).
Long-term Traveler – available to members with dual residences or long-term work assignments
(members are limited to six months out-of-area).
Treat this member as you would a regular Florida Blue HMO member; verify eligibility and benefits, follow
all authorization guidelines, collect member responsibility (i.e., copayment) and file claims to Florida Blue.
File BlueCard Claims to Florida Blue
All claims for BlueCard members should be filed to Florida Blue. Submit the complete member ID number
including the alpha prefix. BlueCard claim processing by Florida Blue is based on eligibility, benefit and
medical coverage guideline information from the member’s Blue Plan. File the claim electronically or send
a paper claim to:
Florida Blue
P.O. Box 1798
Jacksonville, FL 32231-0014
Contact Florida Blue for Claim Inquiries
Florida Blue is your single point of contact for all claim inquiries including claim status, problem resolution
and claim adjustment inquiries. Check BlueCard claim status online using the Availity or call our Provider
Contact Center at (800) 727-2227.
Exceptions
If you contract with a Blue Plan in a contiguous state meaning providers who are located near the border
of Florida may contract with Florida Blue and a Blue Plan in an adjoining state. When you contract directly
with the member’s Plan of a contiguous state, file the claim to that Plan.
•
9
Select ancillary providers (lab, durable medical equipment, home health and specialty pharmacy)
with remote contracts – Refer to the claim filing guidelines.
Medigap Claims - Medicare Complementary/Supplemental Standard
For members who have this type of product you are to file the claim to Medicare for primary payment.
Include the member’s Blue Plan five-digit Medigap insurer ID number, not Florida Blue’s member id
number. The claim will normally be electronically forwarded to the member’s supplement Plan for
processing of secondary benefits. Check the Medicare Remittance Notice to determine if the claim
crossed over.
•
•
If the claim crossed over correctly to the member’s Blue Plan, no action is required.
If the claim did not cross over correctly to the member’s Blue Plan, file a paper claim to Florida
Blue with the Medicare Remittance Notice attached. Florida Blue will route the claim to the
member’s Blue Plan for processing and payment. (Florida Blue does not process the claim.)
Do Not Balance Bill
You may bill the BlueCard member for any deductible, copay, coinsurance or non-covered amounts.
Participating physicians and providers accept the contractually agreed-upon allowance and may not
balance bill the member for the difference between their standard charge and contractual allowance.
Specialty Pharmacy Providers/Remote Provider
Specialty Pharmacy providers are suppliers who dispense drugs and/or drug supplies that are covered
under the medical benefit. The physical locations of Specialty Pharmacies are located throughout the
country; however, the orders submitted are requested by healthcare professionals that are located within
various states and Blues Plan location of service.
In order for a Specialty Pharmacy provider to identify the appropriate 'local plan' for Blue Cross & Blue
Shield (BCBS) members, the ordering provider and ordering provider's location must be
identified. Whenever Specialty Pharmacy services are ordered by a healthcare professional or entity
located within the State of Florida, the participation status of the Specialty Pharmacy Provider will be
determined by its contract status with Florida Blue. Similarly, when the ordering provider or entity is
located outside of the State of Florida, the participation status of the Specialty Pharmacy Provider will be
determined by its contract status with the Blue Cross and Blue Shield plan in the location.
•
•
•
10
Example 1 - Remote Specialty Pharmacy Provider receives an order for a Florida Blue member
from a Provider located within the State of Arizona, the Specialty Pharmacy Provider's 'local plan'
would be BCBS of Arizona.
o The Specialty Pharmacy Provider's contracting arrangement with BCBS of Arizona would
apply to determine if they are a participating or non-participating Specialty Pharmacy.
Example 2 - A Florida Blue provider/entity submits an order to a Specialty Pharmacy Provider, the
Specialty Pharmacy Provider's 'local plan' is Florida Blue.
o If the Specialty Pharmacy Provider has a contracting arrangement with Florida Blue, the
services would process as a participating provider (Caremark LLC is Florida Blue
preferred Specialty Pharmacy Provider).
o If the Specialty Pharmacy Provider does not have a contracting arrangement with Florida
Blue the services would be processed under the policies out of network benefits.
For all Specialty Pharmacies/ Pharmacies that will be billing Florida Blue medical plan for the first time
based upon the Ordering Provider being located within the State of Florida, please refer to the Provider
Registration Form, in order for Florida Blue to obtain the appropriate operating documentation in order to:
•
•
•
•
•
•
Submit and file claims electronically,
Register with Availity,
Receive payment directly,
Receive Electronic Payment Transactions (EFT),
Prevent any delays in the processing of the claim(s), and
Have the ability to utilize Florida Blue Provider Tools
Refer to the Specialty Pharmacy within the Filing a Claim section of the Provider Manual to identify the
billing requirements.
Please reference (Appendix A) for a list of drugs requiring prior approval. If the drug is listed and you are
a Florida Blue in-network par provider please reference the Provider Administered Drug Program (PADP)
for a list of drugs managed by ICORE. If the drug is managed by ICORE please contact ICORE. If the
drug is not listed in PADP or you are not a participating provider please contact Florida Blue at 1-800727-2227.
Provider Networks for Med Advantage PPO Sharing
In Florida, the MA PPO Network Sharing Program applies to providers participating in the BlueMedicare
PPO network.
•
Participating MA PPO (BlueMedicare PPO and BlueMedicare Regional PPO) providers:
o MA PPO (BlueMedicare PPO and BlueMedicare Regional PPO) participating providers
are contractually required to provide care to MA PPO members. Payment will be based
on Florida Blue contracted rates.
Note: Providers that do not have a BlueMedicare PPO or BlueMedicare Regional PPO participating
contract do not include MA PPO Network Sharing language. For these providers, claims will process as
out-of-network.
•
Non-participating providers:
o Non-participating providers may render services but are not required to see MA PPO
members. Payment will be based on Medicare allowed amounts. Urgent or emergency
care will be paid at the Medicare allowed amount based on where services were
rendered.
Members are strongly encouraged to research participating providers in the area in which they will be
visiting/traveling to or permanently residing. Members can call (800) 810-BLUE or visit
www.floridablue.com, under the “Find a Doctor or Hospital” section. (If the alpha prefix is unknown, “994”
can be entered online under the “Guest” tab to display MA PPO providers and facilities.)
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ID Cards
BlueWorldwide Expat ID Card
Stand Alone Health Care Debit Card
12
Combined Health Care Debit Card/Member ID Card
Limited Benefits ID Cards
Limited Benefits Products
Verifying Blue members’ benefits and eligibility is now more important than ever, since new products and
benefit types entered the market. In addition to members with traditional PPO, HMO, POS or other
coverage, which typically has a high lifetime coverage limit of $1 million or more, you may now see
members whose annual benefits are limited to $50,000 or less.
Members who have Blue limited benefits coverage carry ID cards that contain the following information:
13
•
Either of two product names — InReach or MyBasic
•
A tagline in a green stripe at the bottom of the card
•
A black cross and/or shield to help differentiate it from other identification cards
International ID Card
International Members
Occasionally, you may see ID cards from GeoBlue Expat members or international Blue Plan members.
International Blue Plans include BCBS of U.S. Virgin Islands, BCBS of Uruguay, BCBS of Panama and
BCBS of Costa Rica. GeoBlue Expat plans provide medical coverage for employees of U.S.-based
companies doing business abroad. Members enrolled in the GeoBlue Expat product or an International
Blue plans’ product are also covered for services received in the U.S. The coverage for services
received is determined by the international members’ benefits.
These members access the networks of Blue Plans when in the U.S. The International Blue plan ID
cards and the GeoBlue Expat plan ID cards also contain a three-character alpha prefix. Please treat
these members the same as domestic Blue Plan members. Submit all claims from international Blue plan
members or GeoBlue Expat members to Florida Blue.
Note: Claims for members of the Canadian Blue Cross Plans are not processed through the BlueCard
Program. Follow the instructions listed on the ID card. These plans include: Alberta Blue Cross, Manitoba
Blue Cross, Medavie Blue Cross, Ontario Blue Cross, Pacific Blue Cross, Quebec Blue Cross and
Saskatchewan Blue Cross.
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Medicare Advantage Plans
Medicare Advantage Blue Plans indicate PPO, HMO, POS, PFFS or MSA. Following are examples of the
Medicare Advantage identifiers:
Medicare Advantage PPO Network Sharing Program
The “MA” in a suitcase logo on the ID card indicates the member is covered under the program.
Helpful Hints
15
•
Carefully determine the member’s financial responsibility before processing payment. You can
access the member’s accumulated deductible by calling the BlueCard Eligibility line at (800) 676BLUE (2583) or by using the Availity Health Information Network.
•
If the member presents a debit card (stand-alone or combined), be sure to verify the out of pocket
amounts before processing payment:
o Many Plans offer well care services that are payable under the basic health care
program. If you have any questions about the member’s benefits or to request
accumulated deductible information, please call (800) 676-BLUE (2583).
o You may use the debit card for member responsibility for medical services provided in
your office.
o You may choose to forego using the debit card and submit the claims to Florida Blue for
processing. The remittance advice will inform you of the member’s responsibility.
o All services, regardless of whether or not you’ve collected the member responsibility at
the time of service, must be billed to Florida Blue for proper benefit determination, and to
update the member’s claim history.
•
Do not use the card to process full payment upfront. If you have any questions about the
member’s benefits, please call (800) 676-BLUE (2583), or for questions about the health care
debit card processing instructions or payment issues, call the toll-free debit card administrator’s
number on the back of the card.
Authorization Requirements
Precertification and prior authorization can be requested electronically through the Availity Health
Information Network or by phone.
The out-of-area BlueCard member is responsible for obtaining precertification or prior authorization from
their BCBS Plan. However, you may choose to handle this on the member’s behalf.
When the length of an inpatient hospital stay extends past the previously approved length of stay, any
additional days must be approved. Failure to obtain approval for the additional days may result in claims
processing delays and potential payment denials.
The member’s Blue Plan may contact you directly related to clinical information and medical records prior
to treatment or for concurrent review, disease management, or case management for a specific member.
When you call BlueCard Eligibility (800) 676-BLUE (2583), you will be asked for the member’s alpha
prefix on the ID card and routed to the member’s Blue Plan accordingly. Ask for the utilization
management, precertification or authorization area.
Claims Process
After you provide services to a member of another Blue Plan, file the claim to Florida Blue. File claims
electronically through the Availity Health Information Network, whenever possible.
If filing a paper claim, mail to:
Florida Blue
P. O. Box 1798
Jacksonville, FL 32231-0014
Note: Other Blue Plan members are responsible for submitting non-participating provider claims to the
address on the back of their member ID card.
Below is an example of how claims flow through the BlueCard Program:
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Claim Filing Instructions:
•
Lab – Lab providers should file the claim to the Blue Plan in whose service area the specimen
was drawn. If the lab specimen was collected in a Florida location, file to Florida Blue. The claim
will be paid based on your participation status with the Local Plan.
•
DME/HME – DME/HME providers should file the claim to the Blue Plan in whose service area the
equipment or supply was shipped to, or purchased at a retail store. If the equipment was
delivered to a member in Florida, file the claim to Florida Blue. The claim will be paid based on
your participation status with the Local Plan.
•
Specialty pharmacy – Specialty pharmacy generally includes injectable and infusion therapies.
Examples of major conditions these drugs treat include, but are not limited to, cancer, HIV/AIDS,
and hemophilia. Specialty pharmacies should file the claim to the Blue Plan where the ordering
physician is located. If the ordering physician is in Florida, file the claim to Florida Blue. The claim
will be paid based on your participation status with the Local Plan.
Exceptions
There are two situations where you may file claims to other Blue Plans:
1. You Contract with a Blue Plan in a Contiguous State
Providers who are located near the border of Florida may contract with Florida Blue and a Blue Plan in an
adjoining state; see the Contiguous Counties section pg.39 of this manual for claims filing details.
2. Select Ancillary Providers (Lab, Durable/Home Medical Equipment and Specialty Pharmacy)
Blue Plans may contract with providers outside of their exclusive service area for services provided to
local and BlueCard members within their own service area for independent clinical lab, durable/home
medical equipment (DME/HME) and self-administered specialty pharmacy. Blue Plans may not contract
for such services for their members that receive services outside of their service area.
Ancillary claims for independent clinical lab, DME/HME and specialty pharmacy should be filed to the
Local Plan. The Local Plan is the Plan in whose service area the ancillary services are rendered.
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Medicare Advantage Claims
Medicare Advantage (PPO, HMO, PFFS, POS, MSA) claims are not part of the BlueCard Program
(Exception: see the Medicare Advantage PPO Network Sharing Program.
Note: The “MA” inside the suitcase logo will only appear on the ID card of a member from a Plan
participating in the Medicare Advantage PPO Network Sharing Program.
Claim Filing
•
Submit all Medicare Advantage claims to Florida Blue. We will forward the claim to the
appropriate Blue Plan.
•
Indicate on the claim whether you accept Medicare Assignment.
•
Do not bill Medicare directly for any services rendered to a Medicare Advantage member.
Claim Payment
Based upon CMS regulations, if you are a provider who accepts Medicare assignment and renders
service to Medicare Advantage members from other Blue Plans, you will be reimbursed the equivalent of
the currently allowable Medicare amount (i.e., the amount you would collect if the beneficiary were
enrolled in traditional Medicare) for all covered services. CMS regulations state that the Medicare
allowable amount is considered payment in full.
Collect only the applicable member responsibility amounts (deductible, copayment, coinsurance, and
non-covered services) at the time of service. You may not balance bill the member for the difference
between your charge and the allowed amount.
Other than the applicable member cost sharing amounts, reimbursement is made directly by a Blue Plan
under the provisions of the member’s benefit agreement.
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Ancillary Claims Filing
Where should I file Ancillary Claims?
Ancillary providers include Independent Clinical Laboratory, Durable/Home Medical Equipment and
Supplies and Specialty Pharmacy providers. File claims for these providers as follows:
•
Independent Clinical Laboratory (Lab)
o File the claim to the Blue Plan in the service area where the specimen was
drawn. Where the specimen is drawn is determined by where the referring provider is
located.
o The claim will be paid based on your participation status with the Local Plan.
•
Durable/Home Medical Equipment and Supplies (D/HME)
o The Plan in whose state* the equipment was shipped to or purchased at a retail store.
•
Specialty Pharmacy
o The Plan in whose state* the Ordering Physician is located.
*If you contract with more than one Plan in a state for the same product type (i.e., PPO or Traditional),
you may file the claim with either Plan.
For information that applies to ancillary providers with participation agreements that designate the ACFS
as the contractual fee schedule, please use our Ancillary Common Fee Schedule Frequently Referenced
Section.
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Air Ambulance Claims
Air Effective April 19, 2015, claims from providers of emergency and non-emergency air ambulance
services provided within the United States, U.S. Virgin Islands and Puerto Rico are to be filed to the local
Blue Plan in whose service area the point of pickup zip code is located. Generally, you should file claims
for your Florida Blue and/or Florida Blue HMO (Health Options, Inc.) patients to the local Blue Plan
(Florida Blue). However, there are unique circumstances when claims filing instructions will differ based
on the type of service rendered.
When the member’s pickup location is outside the United States, U.S. Virgin Islands and Puerto Rico,
claims should be filed to the BlueCard Worldwide® medical assistance vendor for processing through the
BlueCard Worldwide Program.
NOTE: If you contract with more than one Blue Plan in a state for the same product type (i.e., PPO or
Traditional), you may file the claim with either Blue Plan.
The table below provides examples on how to file air ambulance claims.
Service
Rendered
Air
Ambulance
Services
Please refer
the Inter-Plan
Programs
Manual,
Chapter 6 Claims
Filing
Instructions
and
Scenarios.
20
How to File
(required fields)
Point of Pickup ZIP Code:
−
−
Populate item 23 on the CMS-1500 Health
Insurance Claim Form, with the 5-digit ZIP
code of the point of pickup
− For electronic billers, populate the origin
information (ZIP code of the point of
pick-up), in the Ambulance Pick-Up
Location Loop in the ASC X12N Health
Care Claim (837) Professional.
Where Form CMS-1450 (UB-04) is used for
air ambulance service not included with
local hospital charges, populate Form
Locators 39-41, with the 5-digit ZIP code of
the point of pickup. The Form Locator must
be populated with the approved Code and
Value specified by the National Uniform
Billing Committee in the UB-04 Data
Specifications Manual.
− Form Locators (FL) 39-41
− Code: A0 (Special ZIP code reporting),
or its successor code specified by the
National Uniform Billing Committee.
− Value: Five digit ZIP Code of the location
from which the beneficiary is initially
placed on board the ambulance.
− For electronic claims, populate the origin
information (ZIP code of the point of
pick-up) in the Value Information
Segment in the ASC X12N Health Care
Claim (837) Institutional.
Where to File
Example
File the claim to the Plan in
whose service area the
point of pickup ZIP code is
located*.
• The point of pick up
ZIP code is in Plan A
service area.
• The claim must be
filed to Plan A, based
on the point of pickup
ZIP code.
*BlueCard® rules for claims
incurred in an overlapping
service area and
contiguous county apply.
Medigap Claims
Medicare Complementary/Supplemental Standard A-J policies
The following are guidelines for the filing and processing of Medigap claims:
•
File the claim to your Medicare carrier for primary payment (e.g., for Medicare Part B physician
services in Florida, file to First Coast Service Options).
o Include the correct five-digit Medigap insurer ID number.
o Report only one Medicare supplement insurer.
•
Complete the secondary carrier information with the member’s Blue Plan information (e.g.,
Empire BCBS). If you do not know the member’s Blue Plan, call BlueCard Eligibility at (800) 676BLUE (2583); when you provide the alpha prefix you will be routed to the member’s Blue Plan.
Only indicate Florida Blue when Florida Blue is the member’s secondary coverage.
Not entering the member’s actual Blue Plan as the correct secondary carrier will result in claim issues. A
claim crossed over in error to Florida Blue cannot be processed and you may not receive a remittance.
Therefore, be sure to enter the correct Blue Plan when you submit the claim to Medicare. If your system is
set-up to automatically populate Florida Blue, please change it to the correct Blue Plan.
•
•
Claim information will not be crossed over to the member’s supplement plan (the secondary
payer) until after Medicare has processed the claim and released it from the Medicare payment
hold. Medicare secondary claims will normally be electronically forwarded by GHI (the CMS
vendor) directly to the member’s supplement Blue Plan for processing of the secondary benefits.
After receipt of the Medicare Remittance Notice, review the indicators to identify whether the
claim was crossed over directly to the member’s Medicare supplement Blue Plan.
If the indicator shows the claim crossed over, Medicare has submitted the claim to the appropriate Blue
Plan and the claim is in progress. You do not need to take further action. The 835 (electronic remittance)
records can also carry the secondary forwarding information.
You will receive payment or processing information from the member’s supplement plan after they receive
the Medicare payment. Please allow 45 days from the primary payment date for the processing of the
secondary claim.
If the claim did not crossover electronically to the supplement plan, then file the claim to Florida Blue with
the Medicare Remittance Notice attached. Send the claim to: Florida Blue, P.O. Box 1798, Jacksonville,
FL 32231-0014. Do not send secondary claims directly to the member’s Blue Plan.
Note: If more than one claim appears on the Medicare Remittance Notice, please indicate the specific
claim you are filing.
Direct inquiries on secondary claim to Florida Blue unless the member’s Blue Plan have requested
specific information from you on a particular claim. Inquiries received on secondary claims by Florida
Blue will be coordinated with the member’s Blue Plan for resolution.
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Claim Processing
Once Florida Blue receives a claim, it is electronically routed, based on the alpha prefix, to the member’s
Blue Plan for benefit processing and approval. The member’s Blue Plan determines benefits, coverage
limitations and medical coverage guidelines. Information is returned to Florida Blue. Florida Blue then
completes claim processing, issues any payment due and sends a remittance advice to the provider.
If you have not received payment for a claim, do not resubmit the claim because it will be denied as a
duplicate. This also causes member confusion because multiple explanations of benefits (EOBs) are sent
to the member. Please check claim status using the Availity Health Information Network or call Florida
Blue at (800) 727-2227.
Claim Payment
You may bill the BlueCard member upfront for any deductible, copay, coinsurance or non-covered
amounts. Participating physicians and providers accept the contractually agreed-upon allowance and may
not balance bill the BlueCard member for the difference between their standard charge and contractual
allowance.
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•
BlueCard members with PPO coverage access the PPC network for the lowest out-of-pocket
costs. The allowed amount for covered services is based on the applicable PPC fee schedule
amount.
•
BlueCard members with Traditional, Indemnity, PPO, POS, HMO and Medigap (Medicare
Complementary/Supplemental) coverage may access the Traditional/PPS/PHS network. The
allowed amount for covered services is based on the applicable maximum allowable payable
(MAP)/Traditional/PHS amounts. PPO members may access the Traditional/PPS/PHS network,
but will usually have higher out-of-pocket costs.
Coordination of Benefits
If you discover the member is covered by more than one health plan, and:
•
A Blue Plan is primary – When a Blue Plan is the primary payer, submit the other carrier’s name
and address with the claim to Florida Blue.
•
Another carrier (non-Blue Plan) is primary – When you provide services to a BlueCard member
who has primary coverage with another health insurance carrier (non-Blue plan), file the claim to
the primary carrier first. Once the primary carrier has completed processing, attach the primary
payers’ information (payment/denial notification) to the paper claim and forward to Florida Blue.
Do not submit your secondary claim to the member’s Blue Plan.
Coordination of Benefits Questionnaire
To streamline our claims processing and reduce the number of denials related to coordination of benefits,
a Coordination of Benefits Questionnaire is available at www.floridablue.com (click on Providers, Tools &
Resources, and then Forms) that will help you and your patients avoid potential claim issues. When you
see out-of-area members and you are aware that they might have other health insurance coverage, give
a copy of the questionnaire to them during their visit. Ask them to complete the form and send it to the
Blue Plan through which they are covered as soon as possible after leaving your office. Members will find
the address on the back of their ID card or by calling the customer service numbers listed on the back of
the card. Collecting coordination of benefits information from members before you file their claim
eliminates the need to gather this information later, thereby reducing processing and payment delays.
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Health Information Network
Florida physicians and providers must be connected to the Availity Health Information Network. If you do
not have access to the Availity Health Information Network, register online at www.availity.com. The
Availity Health Information Network provides the electronic gateway for electronic transactions to Florida
Blue. The following e-transactions are available:
•
Eligibility and Benefits Inquiry
•
Health Care Services Review Request (Precertification and Prior Authorization)
• Claim Status Inquiry
Hours of availability for Florida Blue e-transactions are:
•
Monday through Saturday 12 a.m. – 11 p.m., Eastern Time
• Sunday 12 a.m. – 5 p.m., Eastern Time
Occasional system maintenance may affect hours of availability. If the system is unavailable, the Availity
website will display an announcement.
Tutorials and other reference tools are available at www.availity.com.
Printing Information
There is no print capability option for the delayed response information. Therefore, if you need a paper
copy, print the page you are viewing using the browser print option.
Response Times
Eligibility and benefit information and claim status should be available within 24-48 hours. Non-urgent
health care services review requests should be available within 1-14 days of submission. For urgent
health care services requests, please call the telephone number on the member’s ID card. Response time
may also be affected by holiday closings.
The delayed response listings will be available in the mailbox indefinitely.
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Delayed Response for e-Transactions
For Blue Plans that operate in batch-mode or when their real-time system is not available, you will need
to retrieve information on the Eligibility and Benefits Inquiry, Health Care Services Review Request, Claim
Status Inquiry e-transactions from the Delayed Response Application in the Availity Health Information
Network.
Note: To use the Delayed Response Application, you must have the Microsoft Internet Explorer browser.
Steps for Accessing the Delayed Response Application
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•
Select the Delayed Response option on the navigation bar located on the left side of the Availity
screen.
•
Choose the appropriate transaction:
o Eligibility and Benefits Inquiry
o Health Care Services Review
o Claim Status Inquiry
•
First select “Other Blue Plans” as the payer, then select the appropriate Organization. Click on
Submit.
•
Through a pop-up window, you will link to the Florida Blue website to access the delayed
responses from other Blue Plans.
•
Enter the Subscriber ID number or the Submission Date. This creates a listing that only the
requesting provider can view. Click on the blue hypertext to access detailed information.
•
To exit from the Florida Blue website, close out the separate Florida Blue pop-up window. You
will be returned to the Availity screen from where you started.
Medical Records
Blue Plans around the country have made improvements to the medical records process to make it more
efficient. We now are able to send and receive medical records electronically among each other. This
new method significantly reduces the time it takes to transmit supporting documentation for our out-ofarea claims, reduces the need to request records multiple times and eliminates lost or misrouted records.
There are times when the member’s Blue Plan requires medical records to review the claim. The following
are circumstances when the provider may be requested to submit medical records for out-of-area
members.
1. As part of the preauthorization process – If you receive requests for medical records from other
Blue Plans prior to rendering services, as part of the preauthorization process; you will be
instructed to submit the records directly to the member’s Plan that requested them. This is the
only circumstance where you would not submit them to Florida Blue.
2. As part of claim review and adjudication – These requests will come from Florida Blue in the form
of a letter requesting specific medical records and including instructions for submission.
Medical Record Process for Claim Review
1. An initial communication, generally in the form of a letter will be sent to your office requesting the
needed information.
2. You may receive a remittance advice indicating the claim is being denied pending receipt and
review of records. Occasionally, the medical records you submit might cross in the mail with the
remittance advice for the claim indicating a need for medical records. A remittance advice is not a
duplicate request for medical records. If you submitted medical records previously, but received a
remittance advice indicating records were still needed, contact Florida Blue to ensure your
original submission has been received and processed. This will prevent duplicate records being
sent unnecessarily.
3. If you received only a remittance advice indicating records are needed, but you did not receive a
medical records request letter, contact Florida Blue to determine if the records are needed from
your office.
4. Upon receipt of the information, the claim will be reviewed to determine the benefits.
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Helpful Hints for Medical Records
•
If the records are requested following submission of the claim, forward all requested medical
records to Florida Blue.
•
Follow the submission instructions given on the request. Fax the specific records requested and a
copy of the request to (904) 357-6243. Only send BlueCard documentation to this fax line.
•
Include the cover letter you received with the request when submitting the medical records.
Please ensure it is on top of the document or the first page of the transmission as this will route it
to the correct location. This is necessary to make sure the records are routed properly once
received by Florida Blue.
•
Submit the information to Florida Blue within ten business days to expedite processing.
•
Only send the information specifically requested. Frequently, complete medical records are not
necessary and cause unnecessary delays.
•
Please do not proactively send medical records with the claim. Unsolicited claim attachments
may cause claim payment delays.
Status inquiries should be directed to Florida Blue at (800) 727-2227.
•
Provider Appeals
If there is a reduction in payment or a denial of your claim, the remittance advice will provide an
explanation as to the reason for the reduction or denial of the claim. Providers may request
reconsideration of how a claim processed, paid or denied. These requests are referred to as appeals.
To submit an appeal, complete the Provider Reconsideration/Administrative Appeal Form available on the
Florida Blue website, www.floridablue.com.
If the appeal requires a determination from the member’s Plan, Florida Blue will send you a letter
indicating it has been sent to the member’s Plan. If you have not received a response 30 days after
receipt of the letter, contact Florida Blue at (800) 727-2227.
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Frequently Asked Questions
The following answers to frequently asked questions are provided to assist you and your staff in
understanding how the BlueCard Program works.
General
What is the BlueCard Program?
BlueCard is a national program that enables members of one Blue Plan to obtain healthcare service
benefits while traveling or living in another Blue Plan’s service area. The program links participating
healthcare providers with the independent Blue Cross and Blue Shield Plans across the country, and in
more than 200 countries and territories worldwide, through a single electronic network for claims
processing and reimbursement. You may submit claims for patients from other Blue Plans, domestic and
international, to your local Blue Cross and/or Blue Shield Plan. The local Blue Cross and/or Blue Shield
Plan is your sole contact for education, contracting, claims payment/adjustments and problem resolution.
Roles and Responsibilities
What are the roles and responsibilities of the local Blue Cross and/or Blue Shield Plans to their
providers?
Your local Blue Cross and/or Blue Shield Plan’s responsibilities include all provider related functions,
such as:
•
Being the single contact for all claims payment, customer service issues, provider education,
adjustments and appeals.
•
Pricing claims and applying pricing and reimbursement rules consistent with provider contractual
agreements.
•
Forwarding all clean claims received to the member’s Blue Cross and Blue Shield Plan to
adjudicate based on eligibility and contractual benefits.
•
Conducting appropriate provider reviews and/or audits.
•
Confirming that providers are performing services and filing claims appropriately within their
scope of practice and according to their local Blue Cross and/or Blue Shield Plan.
•
Conducting HIPAA standard transactions.
•
Training for providers on BlueCard (Plan optional)
What are the roles and responsibilities of the Member home plan to the provider?
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•
Adjudicate claims based on member eligibility and contractual benefits.
•
Respond to prior authorization and pre-certification requests/inquiries.
•
Request medical records through the local Plan when review for medical necessity, determination
of a pre-existing condition, or high cost/utilization is required.
What are the roles and responsibilities for the Provider?
•
Obtaining benefits and eligibility information, including covered services, copayments and
deductible requirements.
•
Filing claims with the correct local Plan and including, at minimum, the required elements to
ensure timely and correct processing, such as:
o Current member ID card number.
o All Other Party Liability information.
o All member payments such co-pay, co-insurance or deductibles
•
Submitting medical records in a timely manner when requested by the local or member home
Plan
What specific information should the Provider Obtain?
It is recommended that Providers request the most current ID card at every visit since new ID cards
maybe be issued to members throughout the year. Member ID cards may include one of several logos
identifying the type of coverage the member has and/or indicating the provider’s reimbursement level.
•
Blank (empty) suitcase
o Traditional, HMO (Health Maintenance Organization), POS (Point of Service) and Limited
Benefit Product type benefits
•
PPO in suitcase
o PPO or EPO type benefits
•
No suitcase
o Medicaid, State Children’s Health Insurance Programs (SCHIP) administered as a part of
a state’s Medicaid program, Medicare Complementary and Supplemental products, also
known as Medigap type benefits.
The provider should request specific information including eligibility, benefits, cost sharing, prior
authorization/pre-certification requirements, care/utilization management requirements, and concurrent
review requirements when contacting the member home Plan for benefit and eligibility information.
Claim Submission
How should providers bill claims for out-of-area members?
Providers should bill claims for out-of-area members the same way they bill claims for their local Blue
Cross and/or Blue Shield Plan members. When submitting the claim:
•
The member ID numbers should be reported exactly as shown on the ID card. Do not add, omit
or alter any characters from the member ID number.
•
Indicate on the claim any payment you collected from the patient.
• Only submit medical records if requested.
What should you do if you haven’t received a response to your initial claim submission?
If you have a question regarding the status of an outstanding claim, you can submit an electronic Blue
Exchange Claim Status Request (HIPAA transaction 276) or contact your local Plan.
Do not send in a duplicate claim. Sending another claim or having your billing agency resubmit claims
automatically slows down the claims payment process and creates confusion for the member.
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Coordination of Benefits
How should Coordination of Benefits (COB) be handled when a member has Blue on Blue
coverage or another carrier?
In cases where Blue on Blue coverage has been identified, and the member has dual coverage with the
same and/or differing Blue Plans you should consider the following:
•
When submitting the claim, it is essential that you enter the correct Blue Plan name as the
secondary carrier. This may be different from the local Blue Plan. Check the member’s ID card for
additional verification or ask them to complete the Universal Blue COB Questionnaire available
on your local Plan’s website.
•
On the electronic HIPAA transaction 837 or paper claim, it is important in box 11D “YES” or “NO”
be checked for Professional claims or form fields 50, 58-62 be completed for Institutional claims
to ensure the claim will be reviewed properly by the local Blue Plan. For Professional claims if the
member does not have other insurance, it is imperative that you indicate this. Leaving the box
unmarked can cause the Member’s Home Plan to stop the claim to investigate for COB. By
completing the information, you are helping ensure your claim will be processed more timely.
•
Review the EOP/EOB from the primary Blue Plan prior to submitting a claim to the secondary
Blue Plan to avoid duplicate claims submission. The primary Blue Plan may have forwarded the
claim to the secondary Blue Plan through BlueCard. If the secondary claim was not handled by
the local Blue Plan then forward a copy of the claim to your local Blue Plan with any Other Party
Liability (OPL) information included.
•
Carefully review the payment information from all payers involved on the remittance advice before
balance billing the patient for any potential liability.
In cases where there is more than one payer and another Blue Plan or commercial insurance carrier is
the primary payer, submit the other carrier’s name and address or Explanation of Benefits with the claim
to your local Plan. You may also go to your local Plan’s website and download a copy of the Universal
Blue COB Questionnaire that the member can complete and sign at the time of service and send it to
your local Plan with the claim. Please ensure that the form is completely filled out and at a minimum,
include your name and tax identification or NPI number, the policy holder’s name, group number and
identification number including the three character alpha-prefix and the member’s signature. Not including
the COB information with the claim may delay payment if the members home Plan investigates the claim
needlessly.
If another non-Blue health plan is primary and any other Blue Plan is secondary, submit the claim to the
local Plan only after receiving payment from the primary payer. Include the explanation of payment from
the primary carrier with your claim submittal.
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Prior Authorization/Pre-Certification
Are providers required to cooperate with the member’s Blue Plan prior authorization/precertification programs?
While out-of-area BlueCard members are currently responsible for obtaining prior authorization or precertification from their BCBS Plans, most providers choose to handle this obligation on the member’s
behalf. Members may be held financially responsible if necessary approvals are not obtained and the
claim is denied. The provider may have to manage debt collection in this situation.
When verifying member eligibility and benefits, providers should request information on prior authorization
and pre-certification, care management/utilization management and concurrent review, as required for
inpatient or outpatient services.
How can Providers obtain prior authorization/pre-certification information for out-of-area
members?
Member prior authorization or pre-certification information can be obtained both electronically and
telephonically.
•
General information on prior authorization and pre-certification information can be found on the
local Blue Plan webpage under Out-of-Area Member Medical Policy and Pre-Authorization/PreCertification Router utilizing the three letter prefix found on the member ID card.
•
Providers can also contact 1-800-676-BLUE (2583) to obtain prior authorization or precertification information. When prior authorization or pre-certification for a specific member is
handled separately from eligibility verifications at the member’s Blue Plan, your call will be routed
directly to the area that handles prior authorization or pre-certification. You will choose from four
options depending on the type of service for which you are calling:
o Medical/Surgical
o Behavioral Health
o Diagnostic Imaging/Radiology
o Durable/Home Medical Equipment (D/HME)
If you are inquiring about both, eligibility and prior authorization or pre-certification, through 1-800-676BLUE (2583), your eligibility inquiry will be addressed first. Then you will be transferred, as appropriate,
to the prior authorization or pre-certification area.
Please note that if a prior authorization and pre-certification determination is not provided at the time of
the call, the determination may be communicated to a different area (i.e. facility’s Utilization Management
area) than the area that initiated the pre-certification request. Providers are encouraged to ask the
member’s Blue Plan about this situation when they call in order to prevent duplicate requests.
•
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With the submission of an Eligibility HIPAA transaction 270 request through your local Blue Plan,
the Eligibility HIPAA transaction 271 responses may indicate that a prior authorization or precertification is required for an eligible service.
Are facilities that are paid primarily on a DRG/case basis required to obtain approvals for lengthof-stay beyond the original approval?
Whenever possible member Home Plans will consider the local Plan's payment arrangement with the
facility, and if appropriate, adjust UM protocols accordingly. Many DRG contracts have stop loss
provisions and revert to an alternative payment method, i.e., percent of charges, at a particular point
during the course of stay. These cases need to be managed appropriately. Member Home Plans may
work closely with the facility and/or local Plan to manage these potentially high-cost cases.
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•
Claims could be subjected to length-of-stay review and potential sanctions. Providers cannot
assume that if they are contacted as a DRG facility, no concurrent review will occur.
•
The member home plan cannot “split” payment for claims with the local plan DRG pricing. The
member’s home plan must either approve or deny the entire claim. They may not pay only for
specific days and deny others.
•
If the treatment plan changes during the inpatient stay, the original approval would not be
applicable and new certification would need to be obtained. The provider can call 1-800-626BLUE (2583) and request to speak with the Utilization Review area or submit a Blue Exchange
Referral/Authorization Inquiry (HIPAA transaction 278) to the local Plan.
•
Providers are encouraged to inquire about concurrent review process when verifying member
eligibility and benefits or when obtaining pre-certification so they are aware of what steps are
needed to satisfy the member’s Home Plan concurrent review requirements. Provider benefits of
the concurrent review process are:
o Assist with coordinated discharge planning
o Identify care management opportunities for the member
o Help to reduce patient readmission
Why do member’s Blue Plans sometimes initially indicate that a service/procedure is authorized
or certified under an authorization or certification process, but when the service is adjudicated,
determine the service to be non-covered/denied?
These discrepancies tend to occur when there is benefit limitations that restrict; who may render the
service, where they are rendered, how they are billed, or the presence of a benefit maximum. Additional
factors that may affect adjudication of a claim are pre-existing conditions, additional services not included
in the initial plan of treatment and/or a revised length of stay that does not match the prior authorization or
pre-certification.
When obtaining prior authorization or pre-certification, please provide as much information as possible, to
minimize potential claims issues. Providers are encouraged to follow-up immediately with a member’s
Blue Plan to communicate any changes in treatment or setting to ensure existing authorization is modified
or a new one is obtained, if needed. Failure to make the necessary notification or obtain prior
authorization/pre-certification may cause a delay or denial in claims payment. Please note that prior
authorization or pre-certification does not guarantee payment.
Are providers required to hold the patient harmless for penalties assessed for not following the member’s
Blue Plan authorization protocols?
The out-of-area BlueCard member is responsible for obtaining pre-certification or prior authorization from
his/her Blue Cross and/or Blue Shield Plan. As a result, the member is responsible for any penalty
assessed for non-compliance.
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Medical Records
Should a provider include medical records with the original claim?
Providers are not encouraged to submit unsolicited medical records or other clinical information unless
requested. If medical records or other relevant information is needed to finalize the claim payment, the
local Blue Cross and/or Blue Shield Plan will notify you.
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•
If you receive requests for medical records from other Blue Plans prior to rendering services, as
part of the prior authorization process, please submit them directly to the member’s Plan that
requested them.
•
Follow the submission instructions given on the request, using the specified physical or email
address or fax number. The address or fax number for medical records may be different than the
address you use to submit claims.
•
There is a difference between reviewing a claim for medical necessity after the service has
already been rendered and reviewing a prior authorization for medical appropriateness; these
reviews are not the same:
o Medical Necessity - validates the service is medically necessary according to their
members Blue Plan medical policy.
o Medically Appropriate - validates that service rendered matches the prior authorization
and the dollar amounts are in-line.
•
When a claim has been denied for medical records and the records have been submitted to your
local Plan, it is recommended that providers wait at a minimum 20 business days before
submitting a follow up request for status of claim adjudication.
•
If you are the rendering or performing provider for a service, include the name and address of the
referring or ordering provider on your original claim submission. Including this information will help
ensure that if medical records are needed that they will be requested from the correct provider.
Medical, Benefit, Payment Policy
Which Plan’s Medical Policy applies for out-of-area members?
Only a member’s Blue Plan Medical Policy applies to BlueCard claims. The member’s Blue Plan Medical
Policy applies to the interpretation and determination of medical necessity, medical appropriateness,
investigational/experimental care, and clinical reviews as related to administration of the member’s
benefits and coverage.
Should a member’s Blue Plan ever directly contact an out-of-area provider?
The member’s Blue Plan should only contact an out-of-area provider to solicit, clarify, or confirm clinical
information for the purpose of performing case management or disease management activities.
How should providers bill mother/newborn claims for out-of-area members?
Providers should bill mother/newborn services for out-of-area members the same way they bill claims for
local Blue Cross and/or Blue Shield members.
Who determines the use of revenue/procedure codes?
It is the local Plans responsibility for claims coding based on the contractual agreement with the provider.
When a claim contains non-standard codes, it maybe be rejected back to the provider, and the provider
may be asked to resubmit with the standard code.
Who determines the appropriate use of modifiers?
The local Blue Cross and/or Blue Shield Plan is responsible for determining the appropriate use of
modifiers.
How much can a contracted provider bill an out-of-area Blue member?
Providers should only bill for applicable deductibles, co-pays, co-insurance, non-covered services and/or
medical management penalties specifically indicated as “Patient Responsibility” on the remittance advice
for such out-of-area Blue Plan member. The provider cannot, in any event, bill the out-of-area member for
the difference between billed charges and the locally negotiated allowance.
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What criteria are used to determine whether the charge associated with a rendered service is a
member or a contracting provider’s liability?
The criteria used to determine the provider’s liability is specific to the provider’s contract. If the provider’s
contract explicitly states the provider will not be reimbursed for a specific service or based on a specific
timeframe, and cannot bill the member, the provider is liable for the charge.
The criteria used to determine the member’s liability is specific to the member’s benefit contract. If the
member’s benefit explicitly states the service is not covered, the member is liable for the charge.
Under what circumstances is there no payment due to the provider?
Your local Blue Plan prices claims according to the terms of its provider contracts. If a provider’s contract
has a clause stating providers are liable for any costs associated with services rendered outside the
provider’s scope of practice, your local Plan will indicate no payment is due to the provider. If the
member’s benefit allows the service, but the provider’s contract does not, benefits will be approved, but
no payment is due the provider according to his/her contract and the provider should write it off.
Claims Payment
How is a Provider payment determined?
•
The local Plan applies pricing and reimbursement rules consistent with provider contractual
agreements.
•
The member’s home Plan adjudicates the claim based on eligibility and contractual benefits.
Who pays the Provider?
Provider payable claims will be paid by the local Plan based on the provider’s contract and subject to the
member’s benefit plan.
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Medicare Crossover
All Blue Plans crossover Medicare claims for services covered under Medigap and Medicare
Supplemental products. This will result in automatic claims submission of Medicare claims to the Blue
secondary payer, and reduce or eliminate the need for the provider’s office or billing service to submit an
additional claim to the secondary carrier.
How do I submit Medicare primary / Blue Plan secondary claims?
For members with Medicare primary coverage and Blue Plan secondary coverage, submit claims to your
Medicare intermediary and/or Medicare carrier.
•
When submitting the claim, it is essential that you enter the correct Blue Plan name as the
secondary carrier. This may be different from the local Blue Plan. Check the member’s ID card
for additional verification.
•
Be certain to include the alpha prefix as part of the member identification number. The member’s
ID card will include the alpha prefix in the first three positions. The alpha prefix is critical for
confirming membership and coverage, and key to facilitating prompt payments.
When should I expect to receive payment for Medicare Crossover claims?
The claims you submit to the Medicare intermediary will be crossed over to the Blue Plan after they have
been processed by the Medicare intermediary. This process may take up to 14 business days. This
means that the Medicare intermediary will be releasing the claim to the Blue Plan for processing about
the same time you receive the Medicare remittance advice. As a result, it may take additional 14-30
business days for you to receive payment from the Blue Plan.
To determine if your claim has crossed over, review the Remittance Advice (RA) you receive from
Medicare. The RA will show a crossover indicator that Medicare has submitted the claim to the
appropriate Blue Plan and the claim is in progress. If there is no crossover indicator on the RA, providers
should submit the claim along with the Medicare RA to the local Plan.
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Medicare Advantage
How do I handle Medicare Advantage (MA) claims?
For Medicare Advantage, submit claims to the local Blue Plan. Do not bill Medicare directly for any
services rendered to a Medicare Advantage member.
•
•
Ask for the member ID card. Members will not have a standard Medicare card; instead, Medicare
Advantage members have distinctive product logos on their medical ID card to help you
recognize them. All logos have the term “Medicare Advantage” in the design.
Verify eligibility by contacting 1-800-676-BLUE(2583) and providing the alpha prefix. Be sure to
ask if Medicare Advantage benefits apply.
Please review the remittance notice concerning Medicare Advantage plan payment, member’s payment
responsibility and balance billing limitations.
What does Medicare Advantage PPO Network Sharing mean?
If you are a contracted MA PPO provider with the local plan and you see MA PPO members from other
Blue Plans, these members will be extended the same contractual access to care and will be
reimbursed in accordance with your negotiated rate with your local Blue Plan contract. These members
will receive in-network benefits in accordance with their member contract.
NOTE: If you are not a contracted MA PPO provider with your local Plan and you provide services for any
Blue MA members, you will receive the Medicare allowed amount for covered services. For Urgent or
Emergency care, you will be reimbursed at the member’s in-network benefit level. Other services will be
reimbursed at the out-of-network benefit level.
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Contiguous Counties
What are the rules for filing claims for Contiguous Counties?
Claims filing rules for contiguous area providers are based on the permitted terms of the provider contact,
which may include:
•
Provider Location (i.e. which Plan service area is the providers office located)
•
Provider contract with the two contiguous counties (i.e. is the provider contracted with only one or
both service areas).
•
The member’s Home plan and where the member works and resides (i.e. is the member’s Home
Plan with one of the contiguous counties plans).
•
The location of where the services were received (i.e. does the member work and reside in one
contiguous county and see a provider in another contiguous county).
NOTE: Contiguous Counties guidelines do not apply to Ancillary Claims Filing. Ancillary claims must be
filed to the local Plan based on the type of ancillary service provided.
What are the rules for filing claims in Overlapping Service Areas?
Submission of claims in Overlapping Service Areas is dependent on what Plan(s) the Provider contracts
with in that state, the type of contract the Provider has (ex. PPO, Traditional) and the type of contract the
member has with their Home Plan.
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•
If you contract with all local Blue Plans in your state for the same product type (i.e., PPO or
Traditional), you may file an out-of-area Blue Plan member’s claim with either Plan.
•
If you have a PPO contract with one Blue Plan, but a Traditional contract with another Blue Plan,
file the out-of-area Blue Plan member’s claim by product type.
o For example, if it’s a PPO member, file the claim with the Plan that has your PPO
contract.
•
If you contract with one Plan but not the other, file all out-of-area claims with your contracted
Plan.
Additional Information
What is an Administrative Services Only (ASO) account?
ASO accounts are self-funded, where the local plan administers claims on behalf of the account, but does
not fully underwrite the claims. ASO accounts may have benefit or claims processing requirements that
may differ from non-ASO accounts. There may be specific requirements that affect; medical benefits,
submission of medical records, Coordination of Benefits or timely filing limitations.
The local plan receives and prices all local claims, handles all interactions with providers, with the
exception of Utilization Management interactions, and makes payment to the local provider. As with any
member benefit contract be sure to verify member eligibility and benefits when rendering service.
How should clearinghouses be notified of changes in claims processing guidelines or policy?
It is the Providers responsibility to ensure any changes to claims processing guidelines or policy is
communicated to any billing service, clearinghouse or payer the provider has a vendor arrangement with
to process your claims. Failure to do so in a timely manner may result in delays or denials of payment due
to incorrect claims submission.
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