Clarification to billing guidelines for BlueCard® claims for lab, DME, and specialty pharmacy providers

April 18, 2019

BlueCard is a national program offered through the Blue Cross and Blue Shield Association (BCBSA), an association of independent Blue Cross® and Blue Shield® plans, which 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 provides coverage for members by linking participating health care providers through a single electronic network for claims processing and reimbursement. This extensive network provides coverage to members travelling in the U.S. and approximately 170 countries and territories worldwide.

Standardized claims filing guidelines were implemented in 2012 for independent clinical laboratories (lab), durable medical equipment (DME) providers, and specialty pharmacies. This article clarifies the DME guidelines for ancillary providers contracted with Independence.

These billing guidelines do not apply to claims submitted for Federal Employee Program (FEP®) members. For more information about FEP claims filing guidelines, please refer to the FEP website.

Ancillary providers contracted with Independence

Lab (non-hospital based):
​How to file (required fields) Where to file

Referring Provider:

  • Field 17 with qualifier DN on CMS-1500 form, or
  • Loop 2310A (claim level) on 837P (Professional Electronic Submission)

File the claim with the Plan local to the area in which the specimen was drawn. For states with multiple Blue Plans, the state or county in which the referring provider is located will determine where the specimen is drawn.


Example:

  • If an Independence member has a specimen drawn and the referring provider is contracted with Independence, the lab provider must file the claim with Independence.
  • If a BlueCard member has a specimen drawn in the five-county service area (i.e., Bucks, Chester, Delaware, Montgomery, and Philadelphia counties), the lab provider must file the claim with Independence.
  • If a BlueCard member has a specimen drawn outside the five-county Philadelphia region, the lab provider must file the claim with the Plan local to the area in which the specimen was drawn.
DME:

This chart includes a clarification to the billing guidelines.

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 with qualifier DK 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 2310C (claim level) on 837P

File the claim with the Plan local to the service area in which the DME supplies were shipped or received.

Exceptions:

  • For a Highmark member, the DME supplier must file the claim with Highmark, if DME supplies are delivered in the five-county service area.
  • For an Independence member where the DME supplier is contracted with Independence, and DME supplies are delivered in one of the contiguous counties, the claim must be filed with Independence. If outside of the Independence service area (five-county or contiguous counties), the claim must be filed with the local plan where the supplies are being delivered.

Example:

  • If a BlueCard member has DME supplies shipped to or received at a location in the five-county Philadelphia region, the DME supplier must file the claim with Independence.
  • If a BlueCard member has DME supplies shipped to or received in a location outside the five-county Philadelphia region, the DME supplier must file the claim with the Plan local to the area in which the DME supplies were shipped or received.
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 formulary):​
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 with the Plan local to the state or county of the ordering physician.


Example:

  • For an Independence member, regardless of where the referring (ordering) physician is located, the specialty pharmacy provider must file the claim with Independence.
  • If a BlueCard member uses a specialty pharmacy and the referring (ordering) physician is in the five-county Philadelphia region, the specialty pharmacy provider must file the claim with Independence.
  • If a BlueCard member uses a specialty pharmacy and the referring (ordering) physician is outside of the five-county Philadelphia region, the specialty pharmacy provider must file the claim with the Plan local to the area of the ordering physician.

Ancillary providers who are not contracted with Independence or any other Blue Plan

Lab:

For Independence or any other BlueCard member, the lab provider must file the claim with the Plan local to the service area in which the specimen was drawn.

DME:

For Independence or any other BlueCard member, the DME supplier must file the claim with the Plan local to the service area in which the DME supplies were shipped or received. 

Specialty Pharmacy:

For Independence or any other BlueCard member, the specialty pharmacy provider must file the claim with the Plan local to the referring (ordering) physician’s service area.

The claim is considered a nonparticipating provider claim since the ancillary provider does not have a contract with Independence or any other Blue Plan.

Ancillary providers contracted with a Blue Plan other than Independence

If you are contracted with a Blue Plan other than Independence, always file claims with that Blue Plan for services rendered to that Plan’s enrollees. In addition, you should file claims for services rendered to any other BlueCard member in your contracted Blue Plan’s service area to that Blue Plan. For example, a provider contracted with Horizon Blue Cross and Blue Shield (Horizon) should file claims for a BlueCard member with Horizon.

Lab:

File claims for any other BlueCard member with Horizon for specimens drawn in New Jersey.

DME:

File claims for any other BlueCard member with Horizon for DME supplies shipped to or received in New Jersey.

Specialty Pharmacy:

File claims for any other BlueCard member with Horizon when the referring (ordering) physician is located in New Jersey.

If services are rendered to Blue Plan members who are not enrolled with your contracted Blue Plan, or for services rendered outside your contracted Blue Plan's service area, you should file claims according to the guidelines listed below. These claims will be considered nonparticipating claims.

Lab:

File claims with the Plan local to the service area in which the specimen was drawn.

DME:

File claims with the Plan local to the service area in which the DME supplies were shipped or received.

Specialty Pharmacy:

File claims with the Plan local to the ordering physician’s service area.

More information

For more information about the BlueCard Program, visit the BlueCard section or email provider_communications@ibx.com.

Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association.