You have an opportunity to increase the PPO incentive payments earned through our value-based incentive programs, like the Quality Incentive Payment System (QIPS) program, by sending your professional Host claims to Independence. PPO incentive payments are based on the attributed membership on record as of the payment month. To maximize the attribution of National BlueCard® PPO members, practices should submit professional claims to Independence.
Through the BlueCard Program, providers can render services to patients who are enrolled in a Blue Cross® and Blue Shield® Plan – other than one offered by Independence – and patients can visit physicians or facilities within the Independence five-county service area (i.e., Bucks, Chester, Delaware, Montgomery, and Philadelphia counties) for treatment.
There are two BlueCard PPO networks within the Independence five-county service area:
- Personal Choice® (Independence's PPO network)
- Premier Blue (Highmark Blue Shield’s [Highmark] PPO network)
PPO professional providers
PPO professional providers in the five-county network should submit BlueCard claims to the Plan with which they have a contract. A provider who contracts with both networks can choose to submit to either Highmark or Independence for members not covered by Highmark or Independence. Claims for Highmark or Independence members must be submitted to the Plan insuring the member. Here are examples of scenarios:
| Networks | Provider’s contract Plan | Member’s coverage Plan | Provider filing instructions |
|---|
Professional PPO | Independence, Highmark, and Capital Blue Cross | Capital Blue Cross | The provider must submit the claim to Capital Blue Cross, the Plan who holds the member’s coverage. |
Independence and Highmark | Capital Blue Cross | The provider can choose to submit to either Independence or Highmark since they are not contracted with the members coverage Plan. Please see information above for an opportunity to increase the PPO incentive programs by sending your professional Host claims to Independence. |
Independence and Highmark | Independence | The provider must submit the claim to Independence, the Plan who holds the member’s coverage. |
Independence and Highmark | Highmark | The provider must submit the claim to Highmark, the Plan who holds the member’s coverage. |
Highmark | Independence | The provider must submit the claim to Independence, the Plan who holds the member’s coverage. |
Independence | Highmark | The provider must submit the claim to Highmark, the Plan who holds the member’s coverage. |
PPO facility providers
Facility providers in the five-county service area who are contracted with Independence must generally submit BlueCard claims to Independence for adjudication. With limited exceptions (unlike with PPO professional claims), the member’s coverage Plan does not impact which Plan the claim is submitted to for a facility claim. Those exceptions only apply to a PPO facility with a PPO contract with either Highmark or Capital Blue Cross. If the facility treats a member of Highmark or Capital Blue Cross, then those claims must be submitted to the respective Plans. All other PPO facility claims for BlueCard should come to Independence because there is only one PPO facility network in Southeastern Pennsylvania.
All members are subject to eligibility verification and the applicable precertification requirements of their Home Plan.
Ancillary providers
For information and requirements about billing guidelines for lab, DME, and specialty pharmacy providers, please read this article.
Learn more
If you have any questions about submitting BlueCard PPO host claims, contact our Provider Network Services team via email at pnsproviderrequests@ibx.com. Please include “BlueCard PPO host claims” in the subject line of the email.
For more information about the BlueCard Program, visit the BlueCard section.