BCBSA high-dollar prepayment claims review policy

November 29, 2018

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 methodology:
    • Per-diem
    • 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 denied.

More information

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.