Frequently Asked Questions
General
What is the BlueCard Program?
How do I identify a BlueCard member?
What if the member’s ID card does not have a suitcase logo?
What if the member’s ID number does not contain an alpha prefix?
What happens if I do not submit the correct alpha prefix?
How is the applicability of state mandates determined?
What are the roles and responsibilities of the Home Plan and Host Plan?
Eligibility and benefits
What if the Home Plan’s local billing practice is to allow only certain types of providers to render certain services?
May an account dictate the type and/or specialty of providers eligible to perform certain services?
Why is it more common to see benefits restrictions on provider type and provider specialty for behavioral health benefits?
Are Home Plans able to determine a service as noncovered based on their local provider rules?
Is IBC required to enforce a member hold-harmless agreement when the Home Plan denies a service as not covered?
Utilization management
Am I required to cooperate with the member’s Blue Plan preauthorization/precertification programs?
Are facilities that are paid primarily on a DRG/case basis required to obtain approvals for length of stay beyond the original approval?
Am I required to hold the member harmless for penalties assessed for not following Home Plan authorization protocols?
Will the member’s Home Plan ever directly contact me?
May a Home Plan use a determination of medical necessity (medical policy) determination as a way to deny services at an inpatient level, thus only approving as observation services?
How should the claim be handled if the Home Plan allows payment for a service under its medical policy but IBC does not allow it under its provider contract?
How should the claim be handled if the Home Plan doesn’t allow for a service under its medical policy but IBC does under its provider contract?
Coding and billing
May a Home Plan and/or account dictate how claims are billed?
May a Home Plan apply different claim edits (e.g., ClaimCheck®)?
What are the Home Plan requirements for recognizing revenue/procedure codes?
May a Home Plan and/or account dictate the type of claim form upon which services must be billed?
Claims processing
What happens when documentation for medical review is required for a BlueCard claim?
If a BlueCard claim is denied due to lack of medical records, where should I send the documentation?
Why does the member sometimes receive the Explanation of Benefits and payment, not me?
Why are some services denied by other Plans that are covered by IBC?
May Home Plans apply local provider payment policy/requirements when adjudicating claims for services obtained outside the Home Plan’s service area?
Why do Home Plans sometimes indicate that a service/procedure is authorized or certified under an authorization or certification process, but when the service is adjudicated, it is determined to be a noncovered service?
Which Plan is responsible for pricing the claim?
Under what circumstances may IBC indicate that no payment is due to the provider?
What criteria are used to determine whether the charge associated with a rendered service is a contracting provider’s liability?
What criteria are used to determine whether the charge associated with a rendered service is a member’s liability?
May IBC apply local payment criteria if it is an aspect of the provider contracts?
How much may I bill an out-of-area BlueCard member?
General
What is the BlueCard Program?
The BlueCard Program is for members of a Blue Plan obtaining health care services while in another Blue Plan’s service area. It enables those members to receive both the benefits applicable under their benefit agreement and the access applicable to local provider networks. Under the BlueCard Program, the Blue Plan that issued the applicable benefit agreement is known as the “Home Plan,” and the Blue Plan whose network is being used is the “Host Plan.”
How do I identify a BlueCard member?
Most BlueCard PPO members have a “PPO in a suitcase” logo, while Traditional Indemnity, POS, HMO, and Medicare Complementary BlueCard members have a “blank suitcase” logo on the front of their ID card. However, some ID cards may not have a suitcase logo, so you may call BlueCard Eligibility to verify whether the BlueCard Program applies.
What if the member’s ID card does not have a suitcase logo?
This may indicate that the member is not part of the BlueCard Program. To verify this, call the BlueCard Eligibility line at 1-800-676-BLUE (2583). If the ID card has a three-position alpha prefix, send the claim to IBC.
What if the member’s ID number does not contain an alpha prefix?
For ID cards with no alpha prefix, verify that you have the member’s current ID card. Look for claim-filing instructions or a telephone number on the ID card. Do not send the claim to IBC unless indicated on the ID card.
What happens if I do not submit the correct alpha prefix?
The correct alpha prefix is critical to claims routing. Incorrect, transposed, or missing alpha prefixes and numbers may delay claims processing or result in the claim being returned to you because the member cannot be identified and the claim routed correctly.
How is the applicability of state mandates determined?
Host Plans are required to communicate to Home Plans instances when a state mandate may apply.
Each Home Plan must determine whether state mandates apply on a case-by-case basis, reviewing each claim, as well as any applicable law (e.g., preemption under ERISA) that may or may not apply.
Example:
North Dakota (Home Plan) has a state regulation that does not allow social workers to perform certain services; but a member obtains his or her care in Philadelphia. IBC (Host Plan) allows the services to be performed by social workers.
The North Dakota Blue Plan must determine the applicability of its regulation to care obtained outside of its service area. If North Dakota determines that the regulation applies to services obtained in Philadelphia, then the North Dakota Blue Plan may deny the service as noncovered. Home Plans understand that when they deny such a claim, they lose the Host Plan’s discount and the member may be held responsible up to charges.
What are the roles and responsibilities of the Home Plan and Host Plan?
The Home Plan:
- handles all account and member interactions;
- controls sales process and renewal activity;
- is responsible for all member and account communications, including BlueCard disclosure notice;
- is responsible for member and account training and education;
- is responsible for all enrollment activities;
- issues all member identification cards;
- delivers account contracts and member booklets;
- handles all member service activities;
- performs all case management and discharge planning;
- determines medical necessity;
- applies medical policy;
- is responsible for determining available benefits;
- is responsible for all claims adjudication honoring Host Plans bundling/unbundling protocols, network rules, and provider billing practices;
- ensures that no benefits determinations are made based on their Home Plan’s provider payment policies;
- ensures that system logic is not coded to adjudicate based on the Home Plan’s provider payment policy;
- creates member EOBs;
- is responsible for handling all appeals and grievances.
The Host Plan:
- establishes and maintains its provider network;
- determines provider eligibility for its network;
- is responsible for communications with its local providers;
- performs provider contracting, training, and education;
- performs provider site visits, reviews, and credentialing activities;
- receives claims from local providers for all Blue Cross Blue Shield members receiving services in their area;
- provides oversight to confirm that providers are performing services within the scope of their license;
- electronically forwards claims information with price and network indicators, including provider’s participating status, to the Home Plan;
- is responsible for bundling/unbundling practices;
- is responsible for claims coding, including procedure codes, revenue codes, and diagnosis codes;
- determines how modifiers are used (e.g., multiple surgeries, primary/secondary surgeons, and anesthesiology);
- applies pricing, reimbursement, and payment policy rules consistent with the provider agreements;
- informs the Home Plan of any local payment/billing policies via the claims data;
- forwards remittance notices and reimbursements to the providers;
- handles all provider inquiries and provider service.
Eligibility and benefits
What if the Home Plan’s local billing practice is to allow only certain types of providers to render certain services?
The member’s Blue Plan may not deny covered benefits and must honor IBC’s determination of provider eligibility to render such services.
May an account dictate the type and/or specialty of providers eligible to perform certain services?
Yes. An account may exclude specific provider types under the benefit terms of a member’s contract. When a claim is denied for such an excluded provider type, the discount is lost and the member is held responsible up to charges since the services are not a covered benefit.
Why is it more common to see benefits restrictions on provider type and provider specialty for behavioral health benefits?
It is more common to see explicit benefits restrictions that dictate the provider type and specialty that are eligible to render services for behavioral health benefits in conformity with industry standards.
Are Home Plans able to determine a service as noncovered based on their local provider rules?
No. A Home Plan must not determine a service to be noncovered based on its rules applicable to providers in its local area. Home Plans must administer the benefits as specified in the member’s contract.
Is IBC required to enforce a member hold-harmless agreement when the Home Plan denies a service as not covered?
Determining coverage under a benefits agreement is the responsibility of the Home Plan. If the Home Plan denies a service as a noncovered benefit, there is no member hold harmless under the BlueCard Program.
Utilization management
Am I required to cooperate with the member’s Blue Plan preauthorization/precertification programs?
While an out-of-area BlueCard member is responsible for obtaining precertification or prior authorization from his Home Plan, you may choose to handle this obligation on the member’s behalf.
Are facilities that are paid primarily on a DRG/case basis required to obtain approvals for length of stay beyond the original approval?
Failure to obtain approval for additional days may result in potential payment reductions/denials. The out-of-area member would be responsible for any such penalty assessed.
Am I required to hold the member harmless for penalties assessed for not following Home Plan authorization protocols?
No. The out-of-area BlueCard member is responsible for obtaining precertification or prior authorization from his or her Home Plan. In addition, the member is responsible for any penalty assessed for noncompliance.
Will the member’s Home Plan ever directly contact me?
The member’s Blue Plan may contact you directly in situations where utilization review and/or case management are involved.
May a Home Plan use a determination of medical necessity (medical policy) determination as a way to deny services at an inpatient level, thus only approving as observation services?
If a Home Plan determines a service is not medically necessary, and therefore not covered, the member is liable up to billed charges. However, Home Plans cannot apply provider sanctions (e.g., reimbursement policy or local billing practices) to claims for providers outside the Home Plan’s service area.
Contracting providers are allowed to perform services according to the billing/administrative practices of IBC. Home Plans should recognize that the health care delivery system with the Host Plan service area might differ from Home Plan’s local practices. Prior to sending the claim to the Home Plan, IBC will ensure the provider has billed in accordance with his or her contractual agreement and established billing/administrative practices.
How should the claim be handled if the Home Plan allows payment for a service under its medical policy but IBC does not allow it under its provider contract?
If IBC doesn’t allow payment for the service in the provider contract, the claim is the provider’s liability.
How should the claim be handled if the Home Plan doesn’t allow for a service under its medical policy but IBC does under its provider contract?
If IBC allows for the service under its provider’s contract, IBC will apply the IBC price and send the claim to the Home Plan. If the member doesn’t have coverage for the specific service or doesn’t meet the medical necessity criteria for the service, the Home Plan will deny the claim and the claim will be the member’s liability. Only the reimbursement rate is applied by the Host Plan, benefits and medical policy are applied by the Home Plan.
Coding and billing
May a Home Plan and/or account dictate how claims are billed?
Provider billing practices are a Host Plan responsibility that Home Plans must honor. Home Plans may not apply their local billing practices on claims that were rendered in IBC’s service area.
Examples:
- A Home Plan and/or account may not require that anesthesia, when rendered by a certified registered nurse anesthetist, be billed by an anesthesiologist.
- A Home Plan may not dictate how mother/newborn claims are billed. IBC’s billing rules and reimbursement policies dictate if services are billed together or separately.
Exception: If a member’s benefits agreement specifically outlines the manner in which certain services must be billed and/or paid to be considered a covered service, then the Home Plan may deny services and ask IBC to resubmit the claims in a manner that is consistent with the member’s benefits. However, IBC is under no obligation to do so and may not be able to accommodate the request if it conflicts with our contract with the provider. In these situations, a Home Plan may deny the services as noncovered and the member may be held responsible up to charges.
May a Home Plan apply different claim edits (e.g., ClaimCheck®)?
No. The Home Plan must do one of the following:
- accept the bundled claim as priced by IBC;
- deny noncovered services if supported by the member’s benefits agreement or a determination of medical necessity and the member may be responsible up to billed charges.
What are the Home Plan requirements for recognizing revenue/procedure codes?
Home Plans are required to recognize all HIPPA compliant code sets.
When a claim contains nonstandard codes, the Home Plan may reject the claim requesting that IBC resubmit it with a standard code.
May a Home Plan and/or account dictate the type of claim form upon which services must be billed?
No. Provider billing practices are IBC’s responsibility that Home Plans must honor. Home Plans may not apply their local billing practices on claims that were rendered in IBC’s service area.
Claims processing
What happens when documentation for medical review is required for a BlueCard claim?
If medical documentation is required by the member’s Home Plan, IBC will request the documentation from you. The member’s Home Plan is responsible for benefit coverage and medical necessity determinations.
If a BlueCard claim is denied due to lack of medical records, where should I send the documentation?
Medical records should be provided only if the records are specifically requested. The request will include instructions on where to submit the medical records. Normally, IBC will submit the request for the documentation, and we will provide the appropriate IBC address to which records should be mailed. However, under certain circumstances the request for medical records may come directly from the Home Plan. A Home Plan may ask for medical records directly prior to services being rendered to the member. In this instance, the Home Plan will provide the mailing address with its request.
Why does the member sometimes receive the Explanation of Benefits and payment, not me?
This happens when the BlueCard Program does not apply. IBC forwards the claim to the Home Plan for complete processing.
Why are some services denied by other Plans that are covered by IBC?
Each Plan writes its own benefits and creates its own medical policy. Therefore, there are differences, and it is important that you check eligibility and benefits. For example, the State of Pennsylvania mandates coverage for screening mammography benefits for insurance products; this is not the case for all states.
May Home Plans apply local provider payment policy/requirements when adjudicating claims for services obtained outside the Home Plan’s service area?
Home Plans must ensure that they are adjudicating member benefits based on the benefits of the member’s contract and not inadvertently applying local pricing/reimbursement policy.
Why do Home Plans sometimes indicate that a service/procedure is authorized or certified under an authorization or certification process, but when the service is adjudicated, it is determined to be a noncovered service?
These discrepancies tend to occur when there are benefits limitations that restrict who may render the service, where services are rendered, how they are billed, or if there is a benefit maximum. Home Plans are encouraged to communicate these limitations to providers when services are preauthorized or precertified.
Note: Preauthorization and precertification programs generally focus on the proposed site of service and review the appropriateness of that site versus other sites (e.g., outpatient versus inpatient). Providers may wish to inquire concerning coverage of specific benefits when requesting preauthorization or precertification since neither is a guarantee of payment.
Which Plan is responsible for pricing the claim?
Host Plans are responsible for pricing claims. Home Plans must accept a Host Plan’s contracted pricing agreements. If the Home Plan denies a service as noncovered or receives a claim at the billed charge (if there is no Host-contracted rate), the Home Plan may apply its own pricing, but the member may be liable up to charges.
Under what circumstances may IBC indicate that no payment is due to the provider?
If IBC’s provider contract has a clause stating that providers are liable for any costs associated with services rendered outside the provider’s scope of practice, IBC must provide information indicating that no payment is due the provider.
What criteria are used to determine whether the charge associated with a rendered service is a contracting provider’s liability?
Criteria used to determine the provider’s liability are specific to the provider’s contract. If the provider’s contract explicitly states that the provider will not be reimbursed for a specific service and may not bill the member, the provider is liable for the charge.
What criteria are used to determine whether the charge associated with a rendered service is a member’s liability?
Criteria used to determine the member’s liability are specific to the member’s benefits contract. If the member’s benefits explicitly state that the service is not covered, the member is liable for the charge.
May IBC apply local payment criteria if it is an aspect of the provider contracts?
Yes, if it is explicit in the provider’s contract with IBC, IBC must apply local payment criteria to the claim.
Example:
The provider billed 88 units for a specific service, but the provider’s contract allows reimbursement for only 47 units. The provider’s contract explicitly states the provider will not be reimbursed for more than 47 units for the specific service.
- Host Plan — IBC must price the 47 units at the appropriately priced allowance and indicate that no payment is due for the remaining units.
- Home Plan — If the member is eligible for the benefit, the Home Plan should approve the claim as priced and honor IBC’s pricing arrangement with the provider. The provider should not be reimbursed for more than 47 units, and the member is held harmless for all amounts that are discounted in accordance with the provider’s contract.
How much may I bill an out-of-area BlueCard member?
You may bill only for applicable deductibles, copays, coinsurance, noncovered services, and/or medical management penalties specifically indicated as “Patient Responsibility” on the remittance advice for such out-of-area Blue Plan members. You may not, in any event, bill the out-of-area member for the difference between billed charges and the negotiated allowance.
