BCBSA high-dollar prepayment claims review policy update

December 2, 2019

As previously communicated in a Partners in Health UpdateSM article, as of January 1, 2019​, the Blue Cross and Blue Shield Association (BCBSA), an association of independent Blue Cross® and Blue Shield® plans, requires 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.

Mandate update

Effective January 1, 2020, the claims threshold will now be $200,000 or greater as detailed 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 requires the submission of an itemized bill from the participating hospital in order to process claims when each of the following criteria is met:

  • The claim is for inpatient institutional (acute-care) services; and
  • The claim has an estimated allowed amount of $200,000 or greater; and
  • The claim is priced using a global payment methodology that does not incorporate individual services or charges, such as:
    • Per-diem
    • Flat-fee case rate
    • DRG rate

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 below.

Identifying a claim affected by this mandate

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. Use this e-mail address for itemized bill submissions only.

Learn more

If you have additional questions regarding a claim denied as a result of the BCBSA mandate, please email our Provider Network Services team at pnsproviderrequests@ibx.com.

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