You have an opportunity to increase the incentive payments earned through our value-based incentive programs – like the Quality Incentive Payment System (QIPS) program – by sending your professional Host claims to Independence Blue Cross (IBX).
Incentive payments are based on the attributed membership on record as of the payment month. To maximize the attribution of National BlueCard® PPO members, practices should submit professional claims to IBX.
Through the BlueCard Program, providers can render services to patients who are enrolled in a Blue Cross® and Blue Shield® Plan – other than one offered by IBX – and patients can visit physicians or facilities within the IBX five-county service area (i.e., Bucks, Chester, Delaware, Montgomery, and Philadelphia counties) for treatment.
There are two BlueCard PPO networks within the IBX
five-county service area:
-
Personal Choice® (IBX's PPO network)
-
Premier Blue (Highmark Blue Shield's [Highmark] PPO network)
PPO professional providers
PPO professional providers in the five-county network should submit BlueCard claims to the Plan with which they have a contract. A provider who contracts with both networks can choose to submit to either Highmark or IBX for members not covered by Highmark or IBX. Claims for Highmark or IBX members must be submitted to the Plan that insures the member. Here are examples of scenarios:
Professional PPO
| IBX and Highmark
| Capital Blue Cross
| The provider can choose to submit claims to either
IBX or
Highmark since they are
not contracted with the member’s coverage Plan.
Note: If the provider has a contract with Capital Blue Cross, they must submit the claim to
Capital Blue Cross, the Plan that holds the member’s coverage. Please see information above for an opportunity to increase the PPO incentive programs by sending your professional Host claims to IBX.
|
IBX and Highmark
| IBX
| The provider must submit the claim to
IBX, the Plan that holds the member’s coverage.
|
IBX and Highmark
| Highmark
| The provider must submit the claim to
Highmark, the Plan that holds the member’s coverage.
|
Highmark
| IBX
| The provider must submit the claim to
IBX, the Plan that holds the member’s coverage.
|
IBX
| Highmark
| The provider must submit the claim to
Highmark, the Plan that holds the member’s coverage.
|
PPO facility providers
Facility providers in the five-county service area who are contracted with IBX or Highmark can submit BlueCard claims to either IBX or Highmark for adjudication. If the facility treats a member of Highmark, then those claims must be submitted to
Highmark. If the facility treats a member of Capital Blue Cross, then those claims should only be submitted to
Capital Blue Cross if they have a contract with Capital Blue Cross for their members.
All members are subject to eligibility verification and the applicable precertification requirements of their Home Plan.
Ancillary providers
For information and requirements about billing guidelines for lab, DME, and specialty pharmacy providers, please read this
article.
Learn more
If you have any questions about submitting BlueCard PPO host claims, contact our Provider Network Services team via email at pnsproviderrequests@ibx.com. Please include “BlueCard PPO host claims" in the subject line of the email.
For more information about the BlueCard Program, visit the
Products section and select BlueCard from the TAG drop-down menu.
Independence Blue Cross, Capital Blue Cross and Highmark Blue Shield are independent licensees of the Blue Cross and Blue Shield Association.
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