Attention! An update has been made to this page.
BlueCard is a national program offered through the Blue Cross and Blue Shield
Association (BCBSA), an association independent of Blue Cross
? and
Blue Shield
? plans, that enables members of one Blue Plan to obtain
health care benefits and services while traveling or living in another Blue
Plan?s service area. The BlueCard program links participating health care
providers with the various Blue Cross and Blue Shield plans across the U.S. and
in more than 200 countries and territories worldwide through a single
electronic network for claims processing and reimbursement.
The BCBSA and other Blue Plans worked together to clarify existing billing
guidelines regarding BlueCard claims for ancillary providers.
Effective
October 14, 2012, IBC will implement standardized claims filing for durable
medical equipment (DME) providers, independent clinical laboratories, and
specialty pharmacies.
Note: The updated billing guidelines do not apply to claims submitted for
Federal Employee Program (FEP) members.
These claims should continue to be submitted based on FEP claims filing
guidelines.
Ancillary providers contracted with IBC
Independent Clinical Laboratory (Lab) (non-hospital based):
How to file (required fields)
Where to file
Referring Provider:
- Field 17 on CMS-1500 form, or
- Loop 231A (claim level) on 837P (Professional
Electronic Submission)
File the claim to the local Plan in which the specimen was drawn. For states
with multiple Blue Plans, where the specimen is drawn will be determined by the
state or county in which the referring provider is located.
Example:
If an IBC member has a specimen drawn and provider is contracted with IBC, the
lab provider must bill directly to IBC.
If a BlueCard member has a specimen drawn in the 5-county Philadelphia region,
the lab provider must bill directly to IBC.
If a BlueCard member has a specimen drawn outside the 5-county Philadelphia
region, the lab provider must bill to the local Plan where the specimen was
drawn.
Durable/Home Medical Equipment and Supplies (DME):
How to file (required fields)
Where to file
Patient?s Address:
- Field 5 on CMS-1500, or
- Loop 2010CA on 837P
Ordering Physician:
- Field 17 on CMS-1500, or
- Loop 2420E (line level) on 837P
Place of Service:
- Field 24B on CMS-1500, or
- Loop 2300, CLM05-1 on 837P
Service Facility Location Information:
- Field 32 on CMS-1500, or
- Loop 2310 (claim level) on 837P
File the claim to the local Plan for the service area where the DME supplies
were shipped to or picked up from.
Example:
For an IBC member, regardless of where DME supplies are shipped to or picked up
from, the DME supplier must bill directly to IBC.
If a BlueCard member is having DME supplies shipped to or picked up at a
location in the 5-county Philadelphia region, the DME supplier must bill
directly to IBC.
If a BlueCard member is having DME supplies shipped to or picked up at a
location outside the 5-county Philadelphia region, the DME supplier must bill
to the local Plan where the DME supplies were shipped to or picked up.
Specialty Pharmacy (non-routine, biological therapeutics ordered by a health
care professional as a covered medical benefit as defined by the Plan?s
Specialty Pharmacy formula):
How to file (required fields)
Where to file
Referring Provider:
- Field 17B on CMS-1500 form, or
- Loop 2310A (claim level) on 837P
For states with multiple Blue Plans, file the claim to the Plan whose state or
county the ordering physician is located.
Example:
For an IBC member, regardless of where the ordering physician is located, the
specialty pharmacy provider must bill directly to IBC.
If a BlueCard member uses a specialty pharmacy and the ordering physician is in
the 5-county Philadelphia region, the specialty pharmacy provider must bill
directly to IBC.
If a BlueCard member uses a specialty pharmacy and the ordering physician is
outside the 5-county Philadelphia region, the specialty pharmacy provider must
bill to the local Plan where the ordering physician is located.
Ancillary providers who are not contracted with IBC
or any other Blue Plan
Lab:
For IBC or any other BlueCard member, the lab provider must bill the local Plan
for the service area in which the specimen was drawn.
DME:
For IBC or any other BlueCard member, the DME supplier must bill the local Plan
for the service area in which the DME supplies were shipped to or picked up
from.
Specialty Pharmacy:
For IBC or any other BlueCard member, the specialty pharmacy provider must bill
the local Plan for the service area in which the ordering physician is located.
Note: Since the ancillary provider does not have a contract with IBC or
any other Blue Plan, the claim would be considered a nonparticipating provider
claim.
Ancillary providers contracted with a Blue Plan
other than IBC
If you are contracted with a Blue Plan
other than IBC, always bill that
Blue Plan for services rendered to that Plan?s enrollees. In addition, you
should bill services rendered to any other BlueCard member in your contracted
Blue Plan?s service area to that Blue Plan. For example, for a provider
contracted with Horizon Blue Cross and Blue Shield (Horizon):
Lab:
Bill Horizon for specimens for any other BlueCard member drawn in New Jersey.
DME:
Bill Horizon for DME supplies shipped to or picked up in New Jersey for any
other BlueCard member.
Specialty Pharmacy:
Bill Horizon for any other BlueCard member when the ordering physician is
located in New Jersey.
If services are rendered to BlueCard members who are not enrolled with your
contracted Blue Plan or for services rendered outside your contracted Blue
Plan's service area, bill according to the guidelines listed below. These
claims will be considered nonparticipating claims.
Lab:
Bill the local Plan for the service area in which the specimen was drawn.
DME:
Bill the local Plan for the service area in which the DME supplies were shipped
to or picked up from.
Specialty Pharmacy:
Bill the local Plan for the service area in which the ordering physician is
located.
If you have questions or need more information about where to file your claims
for IBC or other Blue Plan members, please contact your IBC Network Coordinator.
Horizon Blue Cross and Blue Shield is an independent
licensee of the Blue Cross and Blue Shield Association.