BlueCard claims from providers of emergency and non-emergency air ambulance services provided within the U.S., U.S. Virgin Islands, and Puerto Rico must be filed with the local Plan in whose service area the point of pick-up occurred.
This Blue Cross and Blue Shield Association requirement applies to the following air ambulance service codes:
• A0430 • A0435 • S9960 • T2007
• A0431 • A0436 • S9961
Claims without a point of pick-up ZIP code, or claims with multiple ZIP codes, will be rejected.
Upon receiving the claim, the Host Plan must validate the point of pick-up ZIP code for air ambulance service on claims. Validation is based on the following guidelines from the Centers for Medicare & Medicaid Services (CMS) for air ambulance claims:
CMS-1500 (2/12) claim form or 837P. In item 23 of the CMS-1500 claim form, or the equivalent field of the 837 professional transaction (loop 2420G), billers shall code the five-digit ZIP code of the point of pick-up. If the ZIP code is not in the Plan's service area, the claim will be rejected.
UB-04 claim form or 837I. When the UB-04 claim form is used for air ambulance service (excluding claims submitted with a facility's negotiated arrangement with an air ambulance provider), billers shall populate Form Locators 39 – 41 with Value Code “A0’ and the five-digit ZIP code of the point of pick-up (corresponding 837I field: Loop 2300, HI01-1 = BE, HI01-2 = A0, HI01-5 = Pick-up ZIP code). The Form Locator must be populated with the approved code and value specified by the National Uniform Billing Committee in the UB-04 Data Specifications Manual.
Format. The format for a ZIP code is five digits. If a nine-digit ZIP code is submitted, the last four digits will be ignored. If the data submitted in the required field does not match that form, the claim will be rejected.
If you have any questions about this requirement, please contact Customer Service at 1-800-ASK-BLUE. For more information about the BlueCard Program, visit the BlueCard section or email firstname.lastname@example.org.
Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association.