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Update: BCBSA high-dollar prepayment claims review policy 

December 26, 2018    

As previously communicated, effective January 1, 2019, the Blue Cross Blue Shield Association (BCBSA) will require all Blue plans to obtain an itemized hospital bill up front, in order to process certain BlueCard® claims for out-of-area members. Providers need to submit an itemized bill when they receive a code on an electronic remittance report (835) and/or paper Provider Remittance as identified below.

In order to comply with the BCBSA mandate, when hospitals participating in Independence’s network treat out-of-area members of another Blue plan, Independence will require the submission of an itemized bill from the participating hospital in order to process claims when each of the following criteria is met:

  • Inpatient institutional (acute-care) claims; and
  • Claims with an estimated allowed amount of $250,000 or greater; and
  • Pricing methodologies except for the following claims pricing models that do not incorporate individual services or charges due to global pricing methodology:
    • Per-diem
    • Flat-fee case rate
    • DRG rate

Note: Claims for members in a Medicare Supplement/Medigap plan or traditional Medicaid are excluded from this prepayment review.

If an itemized bill is not received for claims requiring special treatment in connection with this BCBSA mandate, then the claim may be denied. Providers need to submit an itemized bill when they receive a code on an electronic remittance report (835) and/or paper Provider Remittance as identified below.

Identifying a claim affected by this mandate

If you have a claim affected by this BCBSA mandate, you will see the following codes displayed on your electronic remittance report (835) and/or paper Provider Remittance with the following messages:

  • CARC 252 – An attachment/other documentation is required to adjudicate this claim/service.
  • RARC N26 – Missing itemized bill/statement

Invoice submission instructions

If your claim has been denied, you will need to submit an itemized bill. Please submit itemized bills via email at OOAHighDollarReview@ibx.com. Note: Use this e-mail address for itemized bill submissions only.

More information

If you have additional questions regarding a claim denied as a result of the BCBSA mandate, please email us at providerauditinquiries@ibx.com. Please include BCBSA high-dollar prepayment claims in the subject line.

The Blue Cross and Blue Shield Association (BCBSA) is an association of independent Blue Cross and Blue Shield Plans.





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