Servicing Out-of- Area Blue Members
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- Horace May
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1 Servicing Out-of- Area Blue Members BlueCross BlueShield of Tennessee BlueCard 201
2 Servicing Out-of-Area Members: Overview Contiguous Area Claim Filing Overlapping Service Area Claim Filing Ancillary Providers Claim Filing Air Ambulance Providers Pharmacy, Dental and Vision Providers Telemedicine Providers 2
3 Contiguous Area Claim Filing 3
4 Contiguous Area Claim Filing: Note to Plans A contiguous area is generally a border county in another Plan s service area one county over from the Plan s own service area. Per Brand regulations, a Plan is permitted to use the Brands outside its service area when: Contracting with healthcare providers in a Contiguous Area in order to serve its subscribers residing or working in the Licensee s Service Area. Claims filing rules for contiguous area providers are based on the permitted terms of the contiguous area contract, which may include: The provider s physical location. The provider s contract status with the two contiguous states. The member s Home Plan and where the member works or resides. The location where the member received services. 4
5 Contiguous Area Example: Scenario One Provider is located in one service area and has contracts with both Plans. Dr. Smith is located in Georgia (GA) and has a contract with GA. Alabama Georgia Local Plan 5
6 Contiguous Area Example: Scenario One Provider is located in one service area and has contracts with both Plans. Dr. Smith is located in Georgia (GA) and has a contract with GA. Dr. Smith also has a contiguous area contract with Alabama (AL). Alabama Georgia 6
7 Contiguous Area Example: Scenario One Provider is located in one service area and has contracts with both Plans. Dr. Smith is located in Georgia (GA) and has a contract with GA. Dr. Smith also has a contiguous area contract with Alabama (AL). Alabama Georgia Dr. Smith files a claim to AL for an AL member who resides or works in AL to AL. It is a local AL in-network claim. Local Plan claim AL member 7
8 Contiguous Area Example: Scenario One Provider is located in one service area and has contracts with both Plans. Dr. Smith is located in Georgia (GA) and has a contract with GA. Dr. Smith also has a contiguous area contract with Alabama (AL). Alabama Georgia Dr. Smith files a claim for an AL member who resides or works in AL to AL. It is a local AL in-network claim. Dr. Smith files a GA member's claim to GA. It is a local GA in-network claim. Local Plan claim Local Plan claim AL member GA member 8
9 Contiguous Area Example: Scenario One Provider is located in one service area and has contracts with both Plans. Dr. Smith is located in Georgia (GA) and has a contract with GA. Dr. Smith also has a contiguous area contract with Alabama (AL). Alabama Georgia Dr. Smith files a claim to AL for an AL member who resides or works in AL. It is a local AL in-network claim. Host Plan Dr. Smith files a GA member's claim to GA. It is a local GA in-network claim. Dr. Smith files claims for an AL member who doesn t reside or work in AL or any other Plan s member to GA; regular BlueCard claims filing rules apply. It is a BlueCard in-network claim. IL member -OR- AL member 9
10 Contiguous Area Example: Scenario Two Provider is located in one service area and has a contract only with the Plan in this service area. Dr. Smith is located in GA and has a contract with GA. Alabama Georgia 10
11 Contiguous Area Example: Scenario Two Provider is located in one service area and has a contract only with the Plan in this service area. Dr. Smith is located in GA and has a contract with GA. Dr. Smith has no contiguous area contract with AL. Alabama Georgia 11
12 Contiguous Area Example: Scenario Two Provider is located in one service area and has a contract only with the Plan in this service area. Dr. Smith is located in GA and has a contract with GA. Dr. Smith has no contiguous area contract with AL. Alabama Georgia Dr. Smith files a GA member's claim to GA. It is a local GA in-network claim. Local Plan claim GA member 12
13 Contiguous Area Example: Scenario Two Provider is located in one service area and has a contract only with the Plan in this service area. Dr. Smith is located in GA and has a contract with GA. Dr. Smith has no contiguous area contract with AL. Alabama Georgia Dr. Smith files a GA member's claim to GA. It is a local GA in-network claim. Local Plan Dr. Smith files claims for an AL member and any other Plan s member to GA; regular BlueCard claims filing rules apply. It is a BlueCard in-network claim. -OR- IL member AL member 13
14 Contiguous Area Example: Scenario Three Provider is located in one service area, has no contract with the Plan in this area, and has a contiguous county contract with the other Plan. Dr. Smith is located in GA and has no contract with GA. Alabama Georgia 14
15 Contiguous Area Example: Scenario Three Provider is located in one service area, has no contract with the Plan in this area, and has a contiguous county contract with the other Plan. Dr. Smith is located in GA and has no contract with GA. Dr. Smith has a contiguous area contract with AL. Alabama Georgia 15
16 Contiguous Area Example: Scenario Three Provider is located in one service area, has no contract with the Plan in this area, and has a contiguous county contract with the other Plan. Dr. Smith is located in GA and has no contract with GA. Alabama Georgia Dr. Smith has a contiguous area contract with AL. Dr. Smith files a claim to AL for an AL member who resides or works in AL. It is a local AL in-network claim. Local Plan claim AL member 16
17 Contiguous Area Example: Scenario Three Provider is located in one service area, has no contract with the Plan in this area, and has a contiguous county contract with the other Plan. Dr. Smith is located in GA and has no contract with GA. Alabama Georgia Dr. Smith has a contiguous area contract with AL. Dr. Smith files a claim for an AL member who resides or works in AL to AL. It is a local AL in-network claim. Local Plan Local Plan Dr. Smith files a claim for a GA member to GA. It is a local GA out-of-network claim. claim claim AL member GA member 17
18 Contiguous Area Example: Scenario Three Provider is located in one service area, has no contract with the Plan in this area, and has a contiguous county contract with the other Plan. Dr. Smith is located in GA and has no contract with GA. Dr. Smith has a contiguous area contract with AL. Alabama Georgia Dr. Smith files a claim to AL for an AL member who resides or works in AL. It is a local AL in-network claim. Host Plan Dr. Smith files a claim for a GA member to GA. It is a local GA out-of-network claim. Dr. Smith files claims to GA for IL member or AL member who doesn t reside or work in AL; regular BlueCard claim filing rules apply. It is a BlueCard out-of-network claim. -OR- IL member AL member 18
19 Contiguous Area Example: Scenario Four Provider is located in both service areas and has contracts with Plans in both service areas. Dr. Smith has an office in GA in an area contiguous to AL and an office in AL in an area contiguous to GA. Alabama Georgia 19
20 Contiguous Area Example: Scenario Four Provider is located in both service areas and has contracts with Plans in both service areas. Dr. Smith has an office in GA in an area contiguous to AL and an office in AL in an area contiguous to GA. Dr. Smith has a contract with AL; Dr. Smith has a contract with GA. Alabama Georgia 20
21 Contiguous Area Example: Scenario Four Provider is located in both service areas and has contracts with Plans in both service areas. Dr. Smith has an office in GA in an area contiguous to AL and an office in AL in an area contiguous to GA. Dr. Smith has a contract with AL; Dr. Smith has a contract with GA. Alabama Georgia Dr. Smith sees a GA member in his GA office. The claim is filed to GA. It is a local GA in-network claim. Local Plan claim GA member 21
22 Contiguous Area Example: Scenario Four Provider is located in both service areas and has contracts with Plans in both service areas. Dr. Smith has an office in GA in an area contiguous to AL and an office in AL in an area contiguous to GA. Dr. Smith has a contract with AL; Dr. Smith has a contract with GA. Alabama Georgia Dr. Smith sees a GA member in his GA office. The claim is filed to GA. It is a local GA in-network claim. Dr. Smith sees an AL member who resides or works in AL in his GA office. The claim is filed to AL. It is a local AL in-network claim. Local Plan claim Local Plan claim AL member GA member 22
23 Contiguous Area Example: Scenario Four Provider is located in both service areas and has contracts with Plans in both service areas. Dr. Smith has an office in GA in an area contiguous to AL and an office in AL in an area contiguous to GA. Dr. Smith has a contract with AL; Dr. Smith has a contract with GA. Alabama Georgia Dr. Smith sees a GA member in his GA office. The claim is filed to GA. It is a local GA in-network claim. Dr. Smith sees an AL member who resides or works in AL in his GA office. The claim is filed to AL. It is a local AL in-network claim. Dr. Smith sees an IL member or AL member, not residing or working in AL, in his GA office. The claim is filed to GA; regular BlueCard claim filing rules apply. It is a BlueCard in-network claim. IL member Local Host Plan -OR- AL member 23
24 Contiguous Area Example: Scenario Five Provider is located in both service areas and has a contract with one Plan. Dr. Smith has an office in GA in an area contiguous to AL and an office in AL in an area contiguous to GA. Alabama Georgia 24
25 Contiguous Area Example: Scenario Five Provider is located in both service areas and has a contract with one Plan. Dr. Smith has an office in GA in an area contiguous to AL and an office in AL in an area contiguous to GA. Dr. Smith has a contract with GA but does not have a contract with AL. Alabama Georgia 25
26 Contiguous Area Example: Scenario Five Provider is located in both service areas and has a contract with one Plan. Dr. Smith has an office in GA in an area contiguous to AL and an office in AL in an area contiguous to GA. Dr. Smith has a contract with GA but does not have a contract with AL. Alabama Georgia Dr. Smith sees a GA member in his GA office. The claim is filed to GA. It is a local GA in-network claim. Local Plan claim GA member 26
27 Contiguous Area Example: Scenario Five Provider is located in both service areas and has a contract with one Plan. Dr. Smith has an office in GA in an area contiguous to AL and an office in AL in an area contiguous to GA. Dr. Smith has a contract with GA but does not have a contract with AL. Alabama Georgia Dr. Smith sees a GA member in his GA office. The claim is filed to GA. It is a local GA in-network claim. Dr. Smith sees any other Plan member (IL or AL) in his GA office. The claim is filed to GA; regular BlueCard claim filing rules apply. It is a BlueCard in-network claim. Host Plan -OR- IL member AL member 27
28 Contiguous Area Example: Scenario Five (continued) Provider is located in both service areas and has a contract with one Plan. Dr. Smith has an office in GA in an area contiguous to AL and in AL in an area contiguous to GA. Alabama Georgia 28
29 Contiguous Area Example: Scenario Five (continued) Provider is located in both service areas and has a contract with one Plan. Dr. Smith has an office in GA in an area contiguous to AL and in AL in an area contiguous to GA. Dr. Smith has a contract with GA but does not have a contract with AL. Alabama Georgia 29
30 Contiguous Area Example: Scenario Five (continued) Provider is located in both service areas and has a contract with one Plan. Dr. Smith has an office in GA in an area contiguous to AL and in AL in an area contiguous to GA. Dr. Smith has a contract with GA but does not have a contract with AL. Alabama Georgia Dr. Smith sees an AL member in his AL office. The claim is filed to AL. It is a local AL out-of-network claim. Local Plan claim AL member 30
31 Contiguous Area Example: Scenario Five (continued) Provider is located in both service areas and has a contract with one Plan. Dr. Smith has an office in GA in an area contiguous to AL and in AL in an area contiguous to GA. Dr. Smith has a contract with GA but does not have a contract with AL. Alabama Georgia Dr. Smith sees an AL member in his AL office. The claim is filed to AL. It is a local AL out-of-network claim. Host Plan Dr. Smith sees any other Plan s member (IL or GA) in his AL office; the claim is filed to AL; regular BlueCard claim filing rules apply. It is a BlueCard out-of-network claim. -OR- GA member IL member 31
32 Contiguous Area Example: Scenario Six Provider is located in both service areas and has no contracts with either Plan. Dr. Smith has an office in GA in an area contiguous to AL and in AL in an area contiguous to GA. Alabama Georgia 32
33 Contiguous Area Example: Scenario Six Provider is located in both service areas and has no contracts with either Plan. Dr. Smith has an office in GA in an area contiguous to AL and in AL in an area contiguous to GA. Dr. Smith has no contract with GA and no contract with AL. Alabama Georgia 33
34 Contiguous Area Example: Scenario Six Provider is located in both service areas and has no contracts with either Plan. Dr. Smith has an office in GA in an area contiguous to AL and in AL in an area contiguous to GA. Dr. Smith has no contract with GA and no contract with AL. Alabama Georgia Dr. Smith sees a GA member in his GA office. The claim is filed to GA. It is a local GA out-of-network claim. Local Plan claim GA member 34
35 Contiguous Area Example: Scenario Six Provider is located in both service areas and has no contracts with either Plan. Dr. Smith has an office in GA in an area contiguous to AL and in AL in an area contiguous to GA. Dr. Smith has no contract with GA and no contract with AL. Alabama Georgia Dr. Smith sees a GA member in his GA office. The claim is filed to GA. It is a local GA out-of-network claim. Dr. Smith sees any other Plan member (IL or AL) in his GA office; the claim is filed to GA; regular BlueCard claim filing rules apply. It is a BlueCard out-of-network claim. Host Plan -OR- IL member AL member 35
36 Contiguous Area Example: Scenario Six Provider is located in both service areas and has no contracts with either Plan. Dr. Smith has an office in GA in an area contiguous to AL and in AL in an area contiguous to GA. Dr. Smith has no contract with GA and no contract with AL. Alabama Georgia Dr. Smith sees a GA member in his GA office. The claim is filed to GA. It is a local GA out-of-network claim. Dr. Smith sees any other Plan member (IL or AL) in his GA office; the claim is filed to GA; regular BlueCard claim filing rules apply. It is a BlueCard out-of-network claim. Dr. Smith sees an AL member in his AL office. The claim is filed to AL. It is a local AL out-of-network claim. Local Plan claim AL member 36
37 Contiguous Area Example: Scenario Six Provider is located in both service areas and has no contracts with either Plan. Dr. Smith has an office in GA in an area contiguous to AL and in AL in an area contiguous to GA. Dr. Smith has no contract with GA and no contract with AL. Alabama Georgia Dr. Smith sees a GA member in his GA office. The claim is filed to GA. It is a local GA out-of-network claim. Dr. Smith sees any other Plan member (IL or AL) in his GA office; the claim is filed to GA; regular BlueCard claim filing rules apply. It is a BlueCard out-of-network claim. Host Plan Dr. Smith sees an AL member in his AL office. The claim is filed to AL. It is a local AL out-of-network claim. Dr. Smith sees any other Plan member (IL or GA) in his AL office; the claim is filed to AL; regular BlueCard claim filing rules apply. It is a BlueCard out-ofnetwork claim. GA member -OR- IL member 37
38 Ancillary Providers Claim Filing
39 Ancillary Providers: Claim Filing Ancillary providers claims are filed with the local Plan as follows: Lab Provider Where the specimen was collected. Durable/Home Medical Equipment Provider Where the equipment or supplies were delivered or or purchased. Specialty Pharmacy Provider Where the ordering physician is located. 39
40 Remote Ancillary Providers: Scenario One Note: The following scenarios are applicable to ancillary providers (Lab, DME/HME and Specialty Pharmacy). Lab provider is located in North Dakota (ND) and contracts with BCBS of ND. North Dakota 40
41 Remote Ancillary Providers: Scenario One Note: The following scenarios are applicable to ancillary providers (Lab, DME/HME and Specialty Pharmacy). Lab provider is located in North Dakota (ND) and contracts with BCBS of ND. North Dakota BCBS of Hawaii (HI) has a remote provider contract with this provider for specimens drawn in HI. Hawaii 41
42 Remote Ancillary Providers: Scenario One Note: The following scenarios are applicable to ancillary providers (Lab, DME/HME and Specialty Pharmacy). Lab provider is located in North Dakota (ND) and contracts with BCBS of ND. North Dakota BCBS of Hawaii (HI) has a remote provider contract with this provider for specimens drawn in HI. BCBS of Alabama (AL) member has a specimen drawn in HI. Hawaii AL member 42
43 Remote Ancillary Providers: Scenario One Note: The following scenarios are applicable to ancillary providers (Lab, DME/HME and Specialty Pharmacy). Lab provider is located in North Dakota (ND) and contracts with BCBS of ND. North Dakota BCBS of Hawaii (HI) has a remote provider contract with this provider for specimens drawn in HI. Host Plan BCBS of Alabama (AL) member has a specimen drawn in HI. Hawaii Lab provider files a claim to BCBS of HI. It is a BlueCard in-network claim. AL member 43
44 Remote Ancillary Providers: Scenario Two Note: The following scenarios are applicable to ancillary providers (Lab, DME/HME and Specialty Pharmacy). Lab provider is located in ND and contracts with BCBS of ND. North Dakota 44
45 Remote Ancillary Providers: Scenario Two Note: The following scenarios are applicable to ancillary providers (Lab, DME/HME and Specialty Pharmacy). Lab provider is located in ND and contracts with BCBS of ND. North Dakota BCBS of HI does not have a remote provider contract with this provider for specimens drawn in HI. Hawaii 45
46 Remote Ancillary Providers: Scenario Two Note: The following scenarios are applicable to ancillary providers (Lab, DME/HME and Specialty Pharmacy). Lab provider is located in ND and contracts with BCBS of ND. North Dakota BCBS of HI does not have a remote provider contract with this provider for specimens drawn in HI. BCBS of AL member has a specimen drawn in HI. Hawaii AL member 46
47 Remote Ancillary Providers: Scenario Two Note: The following scenarios are applicable to ancillary providers (Lab, DME/HME and Specialty Pharmacy). Lab provider is located in ND and contracts with BCBS of ND. North Dakota BCBS of HI does not have a remote provider contract with this provider for specimens drawn in HI. Host Plan BCBS of AL member has a specimen drawn in HI. Hawaii Lab provider files a claim to BCBS of HI. It is a BlueCard out-ofnetwork claim. AL member 47
48 Remote Ancillary Providers: Scenario Three Note: The following scenarios are applicable to ancillary providers (Lab, DME/HME and Specialty Pharmacy). Lab provider is located in ND and does not contract with BCBS of ND. North Dakota 48
49 Remote Ancillary Providers: Scenario Three Note: The following scenarios are applicable to ancillary providers (Lab, DME/HME and Specialty Pharmacy). Lab provider is located in ND and does not contract with BCBS of ND. North Dakota BCBS of HI does not have a remote provider contract with the lab company for specimens drawn in HI. Hawaii 49
50 Remote Ancillary Providers: Scenario Three Note: The following scenarios are applicable to ancillary providers (Lab, DME/HME and Specialty Pharmacy). Lab provider is located in ND and does not contract with BCBS of ND. North Dakota BCBS of HI does not have a remote provider contract with the lab company for specimens drawn in HI. BCBS of AL member has a specimen drawn in HI. Hawaii AL member 50
51 Remote Ancillary Providers: Scenario Three Note: The following scenarios are applicable to ancillary providers (Lab, DME/HME and Specialty Pharmacy). Lab provider is located in ND and does not contract with BCBS of ND. North Dakota BCBS of HI does not have a remote provider contract with the lab company for specimens drawn in HI. Host Plan BCBS of AL member has a specimen drawn in HI. Lab provider files a claim to BCBS of HI. It is a BlueCard out-of-network claim. Hawaii AL member 51
52 Remote Ancillary Providers: Scenario Four Note: The following scenarios are applicable to ancillary providers (Lab, DME/HME and Specialty Pharmacy). Lab provider is located in ND and contracts with BCBS of ND. North Dakota 52
53 Remote Ancillary Providers: Scenario Four Note: The following scenarios are applicable to ancillary providers (Lab, DME/HME and Specialty Pharmacy). Lab provider is located in ND and contracts with BCBS of ND. North Dakota BCBS of HI has a remote provider contract with the lab company for specimens drawn in HI. Nebraska Hawaii 53
54 Remote Ancillary Providers: Scenario Four Note: The following scenarios are applicable to ancillary providers (Lab, DME/HME and Specialty Pharmacy). Lab provider is located in ND and contracts with BCBS of ND. BCBS of HI has a remote provider contract with the lab company for specimens drawn in HI. BCBS of NE has a remote provider contract with the lab company for specimens drawn in Nebraska (NE). North Dakota Nebraska Hawaii 54
55 Remote Ancillary Providers: Scenario Four Note: The following scenarios are applicable to ancillary providers (Lab, DME/HME and Specialty Pharmacy). Lab provider is located in ND and contracts with BCBS of ND. BCBS of HI has a remote provider contract with the lab company for specimens drawn in HI. BCBS of NE has a remote provider contract with the lab company for specimens drawn in Nebraska (NE). North Dakota Nebraska BCBS of AL member has a specimen drawn in HI. Hawaii AL member 55
56 Remote Ancillary Providers: Scenario Four Note: The following scenarios are applicable to ancillary providers (Lab, DME/HME and Specialty Pharmacy). Lab provider is located in ND and contracts with BCBS of ND. BCBS of HI has a remote provider contract with the lab company for specimens drawn in HI. BCBS of NE has a remote provider contract with the lab company for specimens drawn in Nebraska (NE). North Dakota Nebraska BCBS of AL member has a specimen drawn in HI. Specimen sent to the regional lab in NE for analysis. Hawaii AL member 56
57 Remote Ancillary Providers: Scenario Four Note: The following scenarios are applicable to ancillary providers (Lab, DME/HME and Specialty Pharmacy). Lab provider is located in ND and contracts with BCBS of ND. BCBS of HI has a remote provider contract with the lab company for specimens drawn in HI. BCBS of NE has a remote provider contract with the lab company for specimens drawn in Nebraska (NE). Host Plan North Dakota Nebraska BCBS of AL member has a specimen drawn in HI. Specimen sent to the regional lab in NE for analysis. Lab provider files a claim for the draw and the analysis to BCBS of HI. It is a BlueCard in-network claim. AL member Hawaii 57
58 Remote Ancillary Providers: Scenario Five Note: The following scenarios are applicable to ancillary providers (Lab, DME/HME and Specialty Pharmacy). Lab provider is located in ND and does not contract with BCBS of ND. North Dakota 58
59 Remote Ancillary Providers: Scenario Five Note: The following scenarios are applicable to ancillary providers (Lab, DME/HME and Specialty Pharmacy). Lab provider is located in ND and does not contract with BCBS of ND. North Dakota BCBS of HI does not have a remote provider contract with this provider for specimens drawn in HI. Hawaii 59
60 Remote Ancillary Providers: Scenario Five Note: The following scenarios are applicable to ancillary providers (Lab, DME/HME and Specialty Pharmacy). Lab provider is located in ND and does not contract with BCBS of ND. BCBS of HI does not have a remote provider contract with this provider for specimens drawn in HI. BCBS of NE has a remote provider contract with this lab company. North Dakota Nebraska Hawaii 60
61 Remote Ancillary Providers: Scenario Five Note: The following scenarios are applicable to ancillary providers (Lab, DME/HME and Specialty Pharmacy). Lab provider is located in ND and does not contract with BCBS of ND. BCBS of HI does not have a remote provider contract with this provider for specimens drawn in HI. BCBS of NE has a remote provider contract with this lab company. North Dakota Nebraska BCBS of AL member has a specimen drawn in HI. Hawaii AL member 61
62 Remote Ancillary Providers: Scenario Five Note: The following scenarios are applicable to ancillary providers (Lab, DME/HME and Specialty Pharmacy). Lab provider is located in ND and does not contract with BCBS of ND. BCBS of HI does not have a remote provider contract with this provider for specimens drawn in HI. BCBS of NE has a remote provider contract with this lab company. North Dakota Nebraska BCBS of AL member has a specimen drawn in HI. Specimen sent to the regional lab in NE for analysis. Hawaii AL member 62
63 Remote Ancillary Providers: Scenario Five Note: The following scenarios are applicable to ancillary providers (Lab, DME/HME and Specialty Pharmacy). Lab provider is located in ND and does not contract with BCBS of ND. BCBS of HI does not have a remote provider contract with this provider for specimens drawn in HI. BCBS of NE has a remote provider contract with this lab company. BCBS of AL member has a specimen drawn in the BCBS of HI. Host Plan North Dakota Nebraska Specimen sent to the regional lab in NE for analysis. Hawaii Lab provider files a claim for the draw and the analysis to BCBS of HI. It is a BlueCard out-of-network claim. AL member 63
64 Remote Ancillary Providers: Scenario Six Note: The following scenarios are applicable to ancillary providers (Lab, DME/HME and Specialty Pharmacy). Lab provider is located in ND and contracts with BCBS of ND. North Dakota 64
65 Remote Ancillary Providers: Scenario Six Note: The following scenarios are applicable to ancillary providers (Lab, DME/HME and Specialty Pharmacy). Lab provider is located in ND and contracts with BCBS of ND. California North Dakota Both California Plans: Anthem Blue Cross and Blue Shield of California have remote provider contracts with this provider. and 65
66 Remote Ancillary Providers: Scenario 6 Note: The following scenarios are applicable to ancillary providers (Lab, DME/HME and Specialty Pharmacy). Lab provider is located in ND and contracts with BCBS of ND. California North Dakota Both California Plans: Anthem Blue Cross and Blue Shield of California have remote provider contracts with this provider. BCBS of AL member has a specimen drawn in California (overlapping service area). and AL member 66
67 Remote Ancillary Providers: Scenario Six Note: The following scenarios are applicable to ancillary providers (Lab, DME/HME and Specialty Pharmacy). Lab provider is located in ND and contracts with BCBS of ND. California North Dakota Both California Plans: Anthem Blue Cross and Blue Shield of California have remote provider contracts with this provider. Host Plan BCBS of AL member has a specimen drawn in California (overlapping service area). and Lab provider files a claim to either Blue Plan in California. It is a BlueCard, in-network claim. AL member 67
68 Remote Ancillary Providers: Scenario Seven Note: The following scenarios are applicable to ancillary providers (Lab, DME/HME and Specialty Pharmacy). Lab provider is located in ND and contracts with BCBS of ND. North Dakota 68
69 Remote Ancillary Providers: Scenario Seven Note: The following scenarios are applicable to ancillary providers (Lab, DME/HME and Specialty Pharmacy). Lab provider is located in ND and contracts with BCBS of ND. California North Dakota Anthem Blue Cross (CA) has a remote provider contract with this provider. BS of CA does not have a remote provider contract with this provider. and 69
70 Remote Ancillary Providers: Scenario Seven Note: The following scenarios are applicable to ancillary providers (Lab, DME/HME and Specialty Pharmacy). Lab provider is located in ND and contracts with BCBS of ND. California North Dakota Anthem Blue Cross (CA) has a remote provider contract with this provider. BS of CA does not have a remote provider contract with this provider. BCBS of AL member has a specimen drawn in California (overlapping service area). and AL member 70
71 Remote Ancillary Providers: Scenario Seven Note: The following scenarios are applicable to ancillary providers (Lab, DME/HME and Specialty Pharmacy). Lab provider is located in ND and contracts with BCBS of ND. California North Dakota Anthem Blue Cross (CA) has a remote provider contract with this provider. BS of CA does not have a remote provider contract with this provider. BCBS of AL member has a specimen drawn in California (overlapping service area). Host Plan Lab provider files a claim to Anthem BC (CA). It is a BlueCard in-network claim. and AL member 71
72 Air Ambulance Claim Filing: Example An air ambulance company located in Nebraska picked up an Illinois member in Wyoming and transported the member to Colorado. The provider should file the claim to Blue Cross and Blue Shield of Nebraska. CO claim NE 72
73 Dental Claims Dental claims are excluded from BlueCard, except for: Dental-related services covered under the member s medical benefits. Member ID cards for standalone dental do not display an alpha prefix. Follow claim filing instructions on the back of the member ID card. 73
74 Pharmacy and Vision Claims Pharmacy and vision benefits can be administered by the member s Blue Plan or by the intermediary (e.g., Davis Vision, Caremark) Claims for prescription drug benefits and vision benefits delivered through an intermediary are filed with the intermediary. Claims for prescription drug benefits and vision benefits that are not delivered through an intermediary should be filed to BlueCross BlueShield of Tennessee. This includes claims for medical vision services covered under the member s medical benefits. 74
75 Telemedicine Claims Telemedicine is the transmitting and receiving of patient s clinical data via electronic communication for the purpose of analysis and interpretation. Telemedicine includes, but it not limited to, telephonic services, internet services and radiology. Telemedicine claims are filed based on where the services are rendered, which is with the Plan in whose service area the provider is physically located. 75
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