As previously communicated, effective January 1, 2019, the
Blue Cross Blue Shield Association (BCBSA), an association of independent Blue
Cross? and Blue Shield? plans, 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
- 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
Identifying a claim affected by this
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.
If you have additional questions regarding a claim denied as a result of the
BCBSA mandate, please email us at email@example.com. Please
include BCBSA high-dollar prepayment claims in the subject line.
Independence Blue Cross is an independent licensee of the
Blue Cross and Blue Shield Association.