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, when requested, in order to process certain
BlueCard? claims for out-of-area members.
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 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
- Any 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 when requested for claims requiring
special treatment in connection with this BCBSA mandate, then the claim may be
Further information and instructions on how to submit an itemized bill
related to this new mandate will be communicated in the next few weeks through
an article in Partners in Health UpdateSM.
Independence Blue Cross is an independent licensee of the
Blue Cross and Blue Shield Association.