Clarification of billing guidelines for BlueCard® claims for DME, independent clinical laboratory, and specialty pharmacy providers

August 31, 2012


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.