The BlueCard Program Provider Manual. December 2010

Transcription

1 The BlueCard Program Provider Manual December 2010

2 Table of Contents What is the BlueCard Program?...3 Responsibilities of the Home and Host Plans...3 Advantages of the BlueCard Program...4 Nonparticipating Providers...4 Products Included in the BlueCard Program...4 How to Identify BlueCard Members...5 BlueCard Traditional...5 BlueCard PPO...5 Foreign Members...5 Consumer-Directed Healthcare and Healthcare Debit Cards...6 Limited Benefit Products...7 Medicare Advantage...8 Types of Medicare Advantage Plans...8 Member Eligibility BlueCard and Blue Cross and Blue Shield Medicare Advantage Alpha Prefixes Contract Numbers Precertification/Preauthorization Filing Claims Coordination of Benefits Electronic Claim Payment/Advice Medical Records Important Information The following disclaimer is applicable to all telephone inquiries and automated communications systems (i.e., telephone and fax) to Blue Cross and Blue Shield of Alabama: The information provided is only general benefit information and is not a guarantee of payment. Benefits are always subject to the terms and limitations of the plan and no employee of Blue Cross and Blue Shield of Alabama has authority to enlarge or expand the terms of the plan. The availability of benefits is always conditioned upon the patient s coverage and the existence of a contract for plan benefits as of the date of service. A loss of coverage, as well as contract termination, can occur under certain circumstances. There will be no benefits available if such circumstances occur. Note: Please refer to our web site, for the most current benefit and policy information. 2

3 What is the BlueCard Program? The BlueCard Program was designed for members of one Blue Plan to obtain benefits for healthcare services while traveling or living in another Blue Cross and Blue Shield Plan s service area. The member could be vacationing or traveling away from home on business. The BlueCard Program links participating healthcare providers and the independent Blue Cross and Blue Shield Plans across the country and in more than 200 countries and territories through a single electronic network for claims processing and reimbursement. The program allows participating Blue Cross and Blue Shield providers in every state to submit claims for indemnity and submit Preferred Provider Organization (PPO) claims and international claims for Blue Cross and Blue Shield subscribers to their local Blue Cross and Blue Shield Plan. Preferred and participating providers in Alabama should submit all claims for any Blue Cross and Blue Shield member directly to Blue Cross and Blue Shield of Alabama. Nonparticipating providers in Alabama filing claims should also send claims for any Blue Cross and Blue Shield member to Blue Cross and Blue Shield of Alabama. Note: All Ancillary Providers (Laboratory, Durable Medical Equipment (DME)/Supplies, Special Pharmacy) should file claims directly to the Blue Plan in the state where the member had the specimen taken or the equipment or special drug delivered. Blue Cross and Blue Shield of Alabama is the provider s sole contact for all claim submissions, payments, adjustments, services and inquiries. (Note: Providers not located in the state of Alabama who may be reviewing this manual and who are not preferred or participating providers with Blue Cross and Blue Shield of Alabama should file claims directly to their local Blue Cross Plan unless they are an ancillary provider (Laboratory, Durable Medical Equipment (DME)/Supplies, Special Pharmacy.) The BlueCard Program has the following two components for members carrying an identification card issued by a Blue Cross and Blue Shield Plan: Home Plan (Member s Plan) Host Plan (Plan where the service was provided, e.g., Blue Cross and Blue Shield of Alabama) Responsibilities of the Home and Host Plans Host Plan Blue Cross and Blue Shield of Alabama Billing guidelines Provider s network status [Preferred Medical Doctor (PMD) or other network] Network Management (education) Sets pricing and other reimbursement guidelines Remittance and reimbursement Provider inquiries for Preferred, Participating and Nonparticipating providers and other servicing of providers Electronic claim inquiries for eligibility and claim status information Medical records Home Plan The Member s Plan Determines member eligibility requirements and benefits Prior authorization requirements ID Cards and Member Explanation of Benefits (EOBs) Member calls and interactions Medical Policy (investigational, medical necessity, etc.) Coordination of benefits Subrogation Case management 3

4 Advantages of the BlueCard Program The BlueCard Program gives providers a central and direct source for handling all Blue Cross and Blue Shield claims. Following are some of the advantages for Blue Cross and Blue Shield of Alabama providers: BlueCard eliminates the need to file claims to multiple Plans and simplifies the billing process. BlueCard also permits providers to file claims electronically and eliminates the need for paper claims. Claims and reimbursement are included in the familiar Blue Cross and Blue Shield of Alabama remittance. Eligibility, benefits and claim status may be confirmed for all Blue Cross and Blue Shield members through ProviderAccess, Blue Cross Online (BCOL) and through Health Insurance Portability and Accountability Act of 1996 (HIPAA) compliant practice management software vendors. Nonparticipating Providers Preferred and Participating providers with Blue Cross and Blue Shield of Alabama contracts are obligated to file claims for members. Non-preferred or nonparticipating providers presented with a Blue Cross and Blue Shield identification card with a suitcase should accept the card and file claims to Blue Cross and Blue Shield of Alabama with other claims. Traditional pricing is based on the member s contract benefits. Products Included in the BlueCard Program The BlueCard Program applies to all inpatient, outpatient and professional claims. In addition, Medicare supplemental claims should be filed through Blue Cross and Blue Shield of Alabama. Do not file claims to Blue Cross and Blue Shield of Alabama and traditional Medicare simultaneously. File claims to Medicare and wait until the Medicare Summary Notice (MSN) or payment advice is received from Medicare. Determine from the MSN if the claim was automatically forwarded to the supplemental insurer. If the claim was not automatically forwarded to the supplemental insurer, file the claim electronically and include Medicare s primary payment. The primary payment information is necessary to file the secondary claim. You may also send a paper claim with the MSN attached to Blue Cross and Blue Shield of Alabama. Traditional (Indemnity), Preferred Provider Organization (PPO) and Health Maintenance Organization (HMO) products are included in the BlueCard Program. Medicare Plans are not considered part of the BlueCard Program but utilize the same processes, systems, claim filing requirements, eligibility and benefit access mechanisms. Exclusions The following claims are excluded from the BlueCard Program: Stand-alone dental Prescription drug products (The back of the member s identification card should include filing instructions for these products.) Claims for the Federal Employee Program (FEP) (Follow the FEP billing guidelines.) Medicare Advantage* *Medicare Advantage is a separate program than BlueCard; therefore, additional information is contained in this manual since providers may see Medicare Advantage members from other Blue Plans. 4

5 How to Identify BlueCard Members When members of Blue Plans arrive at the office or facility make sure to acquire a copy of the Blue Plan membership identification card (ID). It provides essential information about the member and the contract when treating and subsequently filing claims for that member s services. The following information will help you identify different kinds of contracts and offer some information about them. The Blue Cross and Blue Shield Association adopted new ID card rules to achieve more unification among all the Blue Cross Plans by creating a consistent look to the member ID card. The three-character alpha prefix. The PPO in a suitcase logo may appear in the lower right corner of the ID card. BlueCard Traditional BlueCard Traditional is a national program that offers members traveling or living outside of their Plan s area a traditional or indemnity level of benefits when they obtain services from a physician or hospital outside of their Plan s service area. This program does not have Preferred Medical Doctor (PMD) benefits. These claims will process like other non-pmd groups, subject to the member s contract benefits. An empty suitcase on the member s identification card identifies this program. BlueCard PPO BlueCard PPO is a national program that offers members traveling or living outside of their Blue Plan s area the PPO level of benefits when members obtain services from a physician or hospital designated as a BlueCard PPO provider. These members fall under the PMD program and participating hospital agreements with applicable processing guidelines. Medical policy and coverage is based on the Home Plan s guidelines and may be different for these members. A PPO in a suitcase on the identification card identifies this program. Foreign Members Occasionally, you may see identification cards from foreign Blue Cross and Blue Shield Plan members or members of foreign Blue Plans, which include the United States Virgin Islands, Uruguay and Panama. These cards will also contain three character alpha prefixes. Treat these members the same as any other Blue Cross and Blue Shield member. On the following page is a sample of a foreign Blue Cross and Blue Shield identification card. 5

6 Sample ID Card for Foreign Members Front of Card Back of Card Note: The Canadian Association of Blue Cross Plans and its members are separate and distinct from the Blue Cross and Blue Shield Association and its members in the United States. Claims for members of the Canadian Blue Cross Plans are not processed through the BlueCard Program. Please follow the instructions of these Plans as directed by the member s card. The Blue Cross Plans in Canada are: Alberta Blue Cross Atlantic Blue Cross Care Saskatchewan Blue Cross Manitoba Blue Cross Quebec Blue Cross Pacific Blue Cross You may also see patients who are enrolled in the Blue Worldwide Expat product that provides medical coverage for employees of companies based in the United States doing business abroad. Members enrolled in the Blue Worldwide Expat product are covered in the United States for visits of up to 45 days. These members will access the Blue Plan networks in the United States. Please treat these members the same as any domestic Blue Plan member. Submit all claims from International members or Blue Worldwide Expat members to Blue Cross and Blue Shield of Alabama. Front of Card Back of Card Consumer-Directed Healthcare and Healthcare Debit Cards Consumer-Directed Healthcare (CDHC) is a broad umbrella that refers to a movement in the healthcare industry to empower members, reduce employer costs, and change consumer healthcare purchasing behavior. Health plans that offer CDHC provide the member with additional information to make an informed and appropriate healthcare decision through the use of member support tools, provider and network information, and financial incentives. Members who have CDHC plans often carry healthcare debit cards that allow them to pay for out-of-pocket costs using funds from their Health Reimbursement Account (HRA), Health Savings Account (HSA), or Flexible Spending Account (FSA). Some cards are stand-alone debit cards to cover out-of-pocket costs, while others also serve as member ID cards with the member ID number. These debit cards can help simplify the administrative process and may potentially help with the following: Reduce bad debt, Reduce paperwork for billing requirements, Minimize bookkeeping and patient-account functions for handling cash and checks, and Avoid unnecessary claim payment delays. 6

7 These cards have the nationally recognized Blue Cross logos, along with the logo from a major debit card such as MasterCard or Visa. Sample stand-alone healthcare debit card HOLOGRAPHIC MAGNETIC STRIP Sample combined healthcare debit card and member ID card These cards include a magnetic strip for swiping the card at the point of service to collect the member s responsibility (e.g., copayment or other out-of-pocket expenses). The funds will be deducted automatically from the member s appropriate HRA, HSA or FSA account. Combining a health insurance ID card with a source of payment is an added convenience to members and providers. Members can use their cards to pay outstanding balances on billing statements. They may also use their cards via telephone in order to process payments. In addition, members are more likely to carry their current ID cards because of their payment capability. If the office is set up to accept credit card payments, there are no additional costs or equipment necessary. The cost is the same as any other signature debit card. Limited Benefit Products A limited benefit product is a plan that offers limited or a reduced set of benefits to the beneficiary as compared to the other major health plans. The cost of limited benefit products are less than traditional insurance policies. Verifying Blue patients benefits and eligibility is more important than ever before since new products and benefit types have entered the market. Currently Blue Cross and Blue Shield of Alabama does not offer limited benefit plans to our members; however, you may see patients with limited benefits covered by another Blue Plan. How to recognize members with limited benefit products? Following are sample ID Cards for patients with Blue limited benefits coverage: 7

8 The product names are InReach or MyBasic. ID cards have a green stripe at the bottom of the card and the cross and shield symbols are black rather than the traditional blue. Obtain a copy of the patient s ID card and verify the patient s benefits and eligibility just as you would any other Blue Plan members. The information will be able to identify the remaining benefits left for the member. If the cost of services extends beyond the patient s benefit coverage limit, inform the patient of any additional liability they might have. What should I do if the patient s benefits are exhausted before the end of their treatment? Annual benefit limits should be handled in the same manner as any other limits on the medical coverage. Any services beyond the covered amounts or the number of treatment might be the member s liability. Medicare Advantage The Balance Budget Act of 1997 (Pub. L ) established a Medicare program called Medicare + Choice (M+C), now known as Medicare Advantage (MA). The intent of the program is to significantly expand the healthcare options available to Medicare beneficiaries in addition to the traditional Medicare program. The Medicare Modernization Act of 2003 (MMA) made many changes to the Medicare Program by not only providing prescription drug benefits but transforming the M+C program into the Medicare Advantage (MA) program. With the MMA s improvements to the M+C program, such as preventive benefits, disease management programs, etc., beneficiaries have access to modern integrated health insurance plans, including PPO plans with drug coverage. MA programs offer Medicare beneficiaries several product options, and all MA plans must offer beneficiaries at least standard Medicare Parts A and B benefits. However, many plans offer additional covered services. Medicare Advantage Plans may allow in and out of network benefits, depending on the type of product that the member selected. Providers should confirm the level of coverage [by calling BLUE (2583)] or by submitting an electronic inquiry for all Medicare Advantage members prior to provider service since the level of benefits and coverage rules may vary depending on the plan. Many Blue Cross and Blue Shield Plans have been authorized by the Centers for Medicare and Medicaid Services (CMS) to offer these products. The Blue Cross Plan is the primary payer for Medicare Advantage claims, rather than traditional Medicare. Blue Cross and Blue Shield of Alabama is one of the Plans that have been approved as a Medicare Advantage Organization (MAO). Blue Advantage is Blue Cross and Blue Shield of Alabama s Medicare Advantage PPO, an alternative to traditional Medicare. Types of Medicare Advantage Plans The Blue Cross and Blue Shield Association has mandated that the Medicare Advantage logo be affixed to Medicare Advantage identification cards so providers can easily identify the member as a Blue Cross and Blue Shield member participating in a Medicare Advantage Plan. (The logos are shown in the following section.) There are a number of Medicare Advantage plans available to members in addition to the PPO plan, such as HMOs, point-of-service (POS) and private fee-for-service (PFFS). Members have identification cards similar to the Blue Cross and Blue Shield member card. Medicare Advantage HMO A Medicare Advantage HMO is a Medicare-managed care option in which members typically receive a set of predetermined and prepaid services provided by an established network of physicians and hospitals. Generally (except in urgent or emergency care situations), medical services are only covered when provided by these in-network providers. The level of benefits and the coverage rules may vary by Medicare Advantage Plan. 8

9 Medicare Advantage PFFS Medicare Advantage Private Fee-for-Service (PFFS) members may go to any Medicare-approved physician or hospital that accepts the Plan s terms and condition of participation. The Medicare Advantage organization, rather than the Medicare program, pays physicians and providers on a fee-for-service basis for services rendered to such members. Members are responsible for cost-sharing, as specified in the benefit plan. Following are ways Medicare Advantage PFFS plans vary from the other Blue products you might currently participate in such as Blue Advantage: You can see and treat any Medicare Advantage PFFS member without having a Blue Advantage agreement with Blue Cross and Blue Shield of Alabama. If you provide services, you do so under the Terms and Conditions of that member s Blue Plan. The MA PFFS Terms and Conditions (benefits) for all Blue Plans can be found at just as you would any Blue Cross contract by using the contract number and prefix. Submit all Medicare Advantage PFFS claims directly to Blue Cross and Blue Shield of Alabama. Claims process much the same way as traditional Medicare, usually without the member copayment (view Member benefits). Medicare Advantage PPO A Medicare Advantage PPO plan has a network of providers, but unlike traditional HMO products, that allows members access to services provided outside the contracted network of providers. Required member cost-sharing may be greater when covered services are obtained out of network. Medicare Advantage PPO plans are offered on a local and regional basis. The Medicare Advantage PPO product for Blue Cross and Blue Shield of Alabama is Blue Advantage PPO. Other Blue Cross Plans may have different names for their PPO product, but the logo below should be present on the member s card for easy identification. Network Sharing In January 2010, Blue Medicare Advantage PPO Plans began participating in a reciprocal network sharing. This network sharing allows all Blue MA PPO members to obtain in network benefits when traveling or living in the service area of another Blue MA PPO Plan as long as the member sees a Medicare Advantage contracted provider. Blue Advantage PPO providers should treat Medicare Advantage members from another Blue Plan the same as they would a BA member. Reimbursement is made in the same manner as the Blue Advantage PPO claims. Providers are under the same obligations with respect to balance billing for anything other than the member s deductibles, coinsurance and copayments. Members receive in-network benefits in accordance with their member contract. If a provider is not a Blue Advantage PPO provider and provides services to one of these members, the provider will receive the Medicare-allowed amount for covered services. For urgent or emergency care, reimbursement is made at the member s in-network benefit level. Other services are reimbursed at the out-of-network benefit level. 9

10 Medicare Advantage Medical Savings Account A Medicare Advantage Medical Savings Account (MSA) is a Medicare health plan option made up of two parts. One part is a Medical MSA Health Insurance Policy with a high deductible. The other part is a special savings account where Medicare deposits money to help members pay their medical bills. Claims for all Medicare Advantage plans, regardless of the type of plan, should be filed to the local Blue Cross and Blue Shield Plan (Alabama) and not the traditional Medicare carrier. Blue Cross and Blue Shield of Alabama provides payment and claim processing information. Verify eligibility by submitting an electronic inquiry to Blue Cross and Blue Shield of Alabama, including the prefix. You may also verify eligibility by contacting BLUE (2583). Providers who are not participating with the Blue Cross and Blue Shield of Alabama Blue Advantage program, but do participate and accept assignment with traditional Medicare are generally considered to be non-contracted providers with these programs. They are reimbursed the equivalent of the current Medicare-allowed amount for all covered services (e.g., the amount that you would have been paid under the traditional Medicare program for these services). Member Eligibility - BlueCard and Blue Cross and Blue Shield Medicare Advantage For Alabama providers, Blue Cross and Blue Shield of Alabama cannot answer questions about the BlueCard and other Blue Cross Medicare Advantage member s benefits or eligibility because the member s benefits are administered by another Blue Cross Plan. Following are two ways to obtain information for BlueCard and Blue Cross and Blue Shield Medicare Advantage member eligibility: 1. Electronically: Eligibility, benefits and claim status may be confirmed electronically for all Blue Cross and Blue Shield members, even out-of-state contracts (BlueCard ) and Blue Cross Medicare Advantage members. Requests for eligibility are routed electronically to the Home Plan based on the contract prefix. Contract information is available through ProviderAccess, Blue Cross Online (BCOL) and through HIPAA compliant practice management software vendors. Use the same method as you do for your Blue Cross and Blue Shield of Alabama members. The service hours have been extended to accommodate access to electronic patient information. The system is now available from 6 a.m. to midnight, Monday through Saturday, Central Standard Time. Submit your requests electronically and receive real-time responses. There will be several additional enhancements in the electronic arena, including the availability of more detailed eligibility information for BlueCard members as the Blue Cross and Blue Shield Plans work to create a seamless and efficient system among the Blue Plans. 2. Telephone: To verify membership and coverage, with the member s most current identification card in hand, call BlueCard Eligibility at BLUE (2583). An operator will ask for the alpha prefix on the member s identification card, or the provider may enter it at that prompt. The call will be automatically connected to the appropriate membership and coverage unit at the member s Blue Cross and Blue Shield Plan. Operators are available to assist providers weekdays during regular business hours from 7 a.m. to 10 p.m., Eastern Standard Time. Keep in mind that Blue Cross and Blue Shield Plans are located throughout the country and may operate on a different time schedule than Blue Cross and Blue Shield of Alabama. English-speaking and Spanish-speaking telephone operators are available to assist you. Providers may be transferred to a voice response system linked to customer service enrollment and benefits or may need to call back at a later time. 10

11 Alpha Prefixes The alpha prefix on the member s identification card is a key element used to correctly identify and route claims. The alpha prefix identifies the Blue Cross and Blue Shield Plan to which the member belongs. An incorrect alpha prefix on a claim may result in a claim denial or delay in processing. The alpha prefix is also important for verifying membership and coverage correctly. Do not make up alpha prefixes. Note: An identification card with no alpha prefix may indicate that the claims are handled outside of the BlueCard Program. Look for instructions or a telephone number on the back of the member s identification card for information on how to file these claims. If no information is listed, call Blue Cross and Blue Shield of Alabama for assistance at This number is for an automated voice response unit with representatives available to assist providers who do not have access to the toll- free number. Contract Numbers The contract number is combined with the alpha prefix for the member s complete identification number. It is important that the complete number is used when filing claims. Blue Cross and Blue Shield of Alabama traditionally has a contract number that has three alpha prefix characters and nine numbers that were historically the member s social security number. Due to HIPAA Privacy, all Blue Cross and Blue Shield contract numbers have been changed to reflect numbers other than the member s social security number. Some Blue Cross and Blue Shield Plans have more than nine characters for the identification number, including some with alpha characters within the contract number. Blue Cross and Blue Shield of Alabama can accept any Blue Cross and Blue Shield identification number of any length and with any combination of numbers and alpha characters. For electronic claims, the provider s vendor must program sufficient space to allow for the entire contract number to be submitted. Do not make up alpha prefixes for the member s contract number. It is important to secure a copy of your patient s most current identification card and verify any changes in their insurance information. Obtaining accurate contract information assists in accurate and timely claim filing and processing. Precertification/Preauthorization Remind patients from other Plans that they are responsible for obtaining precertification and/or preauthorization for their services from their Blue Cross and Blue Shield Home Plan. When the length of an inpatient stay extends past the previously approved length of stay, any additional days must be approved. Failure to obtain approval for the additional days may result in claims processing delays and potential payment denials. The provider may choose to contact the member s Plan on behalf of the patient. Following are the ways to contact the member s Plan: Electronically: Submit a HIPAA 278 transaction (referral/authorization) to Blue Cross and Blue Shield of Alabama. Telephone: Call BlueCard Eligibility at BLUE (2583) for membership and coverage information and ask to be transferred to the utilization review area. 11

12 Filing Claims Following is how a claim flows through the BlueCard system: * (see below) 1. A member of another Blue Plan receives services from you, the provider. 2. The provider submits the claim to the local Blue Plan. 3. The local Blue Plan recognizes the BlueCard member and transmits a standard claim format to the member s Blue Plan. 4. The member s Blue Plan adjudicates the claim according to the member s benefit plan. 5. The member s Blue Plan issues an EOB to the member. 6. The member s Blue Plan transmits claim payment disposition to your local Blue Plan. 7. Your local Blue Plan pays you the provider. The flow of claims through BlueCard happens electronically, but there are guidelines that will assist you in making this process as smooth as possible. When a member from another Blue Cross and Blue Shield Plan visits a PPO/PMD, follow the guidelines below: Ask members for their current member ID cards and regularly obtain new photocopies. Having the current card enables providers to submit claims with the appropriate member information (including alpha prefix) and avoid unnecessary claims payment delays. Verify membership and coverage by submitting a HIPAA 278 transaction (referral/authorization) to Blue Cross and Blue Shield of Alabama or call BLUE (2583). Remind patients they are responsible for obtaining precertification authorization from their Home Blue Cross and Blue Shield Plan. After providing care, file the claim electronically to Blue Cross and Blue Shield of Alabama. Be sure to include the complete contract number including the alpha prefix and any and all combination of numbers and letters that may be in the contract number. Blue Cross and Blue Shield of Alabama electronically routes the claim to the member s Blue Cross and Blue Shield Plan. The member s Plan adjudicates the claim, approves payment, and transmits the disposition to Blue Cross and Blue Shield of Alabama. Blue Cross and Blue Shield of Alabama reconciles payment and forwards it to the provider along with a remittance notice. The member s Plan sends an Explanation of Benefits to the member. All Blue Cross and Blue Shield claims with a suitcase on the member s identification card (whether empty or with a PPO inside), as well as Medicare Advantage members, should be filed to Blue Cross and Blue Shield of Alabama. Be sure to include the member s complete identification number when filing. Include the alpha prefix and all of the following numbers or letters. Do not make up alpha prefixes. Incorrect or missing alpha prefixes and member identification numbers may cause claims to reject or delay processing. Blue Cross and Blue Shield of Alabama encourages providers to file BlueCard claims electronically along with other claims. Note: Blue Cross and Blue Shield of Alabama s PMDs located in a county that borders the state of Alabama should file all Alabama contracts to Blue Cross and Blue Shield of Alabama and not to the Blue Cross Plan in the state where the practice is located. Blue Cross and Blue Shield contracts that are not Blue Cross and Blue Shield of Alabama contracts should be filed to the local Blue Cross and Blue Shield Plan for the state where the practice is located. * Remote Ancillary Providers A remote ancillary provider is an independent clinical laboratory, durable/home medical equipment and specialty pharmaceutical provider located outside of Alabama. Claim filing rules for these remote providers has been clarified and results in a change. Claims for independent clinical laboratories should be filed to the Blue Plan 12

13 where the specimen was drawn and not to the local Plan where the laboratory is located. Durable/medical equipment suppliers should file claims to the Blue Plan where the supplies or equipment were shipped to or purchased by the member. Specialty pharmaceutical providers should file claims to the Blue Plan of the ordering physician. Claims for these services are subject to any medical policy and fragmented coding edits that are in place for any in-state ancillary providers. Traditional Medicare The Blue Cross and Blue Shield Association requires all Plans to handle Medicare secondary claims with a Blue Cross and Blue Shield contract as primary through BlueCard. Alabama providers no longer have to file these claims directly to the member s Home Plan, but rather send them directly to Blue Cross and Blue Shield of Alabama. If these claims are filed directly to the member s Home Plan they may be returned with instructions to file with the local Plan, Blue Cross and Blue Shield of Alabama. File all Medicare primary claims to the local Medicare Carrier initially. Do not file the claim to Blue Cross and Blue Shield of Alabama and Medicare simultaneously. Wait until the Medicare Summary Notice (MSN) or summary advice is received. Determine from the MSN if Medicare automatically forwarded the claim to the supplemental insurer. Typically, the MSN will have a Remark Code MA18 printed that states The claim information is also being forwarded to the patient s supplemental Insurer. If Medicare has forwarded the claim, do not file for Medicare supplemental benefits. If the Medicare MSN does not indicate the claim has been forwarded, file the claim to Blue Cross and Blue Shield of Alabama. Payment All Blue Cross and Blue Shield claims should be filed to the local Plan, Blue Cross and Blue Shield of Alabama. These claims will be processed based on local processing guidelines (Alabama). Claims are electronically submitted to the member s Home Plan for verification of eligibility and contract benefits. The Home Plan submits information relative to adjudication of the claim back to Blue Cross and Blue Shield of Alabama. The claim will appear on the provider s regular Blue Cross and Blue Shield of Alabama remittance. BlueCard PPO claims will appear in the preferred section of the remittance and BlueCard traditional claims will appear in the Non-Preferred section of the remittance with the appropriate pricing and payment. Coordination of Benefits Coordination of benefits (COB) refers to how Blue Cross and Blue Shield of Alabama ensures that the member receives full benefits and prevents duplicate payment for services when the member has coverage from two or more sources. It is necessary to contact each Plan covering a patient to determine the order in which benefits should be considered. Utilize the BlueCard Eligibility number at BLUE (2583) or another resource to determine if the member s benefit plan has a COB provision. Electronic Claim Payment/Advice BlueCard Medicare Advantage claims filed to Blue Cross and Blue Shield of Alabama are processed and electronically forwarded to the member s Home Plan for eligibility and benefit verification. Prior to October 16, 2003, claims from Preferred and Participating Providers were often processed outside the BlueCard system. The HIPAA Transactions and Code Sets regulations require the implementation of specific standards for transactions and code sets effective October 16, One of those standard transactions is the ANSI ASC X12N 835 Claim Payment/Advice transaction. This 835 transaction extends to all claims. Home Plans that normally process claims outside of the BlueCard system are required by HIPAA to provide the 835 transactions to those providers who have requested this transaction. Reimbursement for these types of claims is made based on the member s out-of-network benefit rather than the contractual rate. A remittance code of CE indicates the claim paid outside contractual and identifies claims that have been removed from the 13

14 BlueCard Program and are processed outside the PMD, Blue Cross and Blue Shield Medicare Advantage or other participating arrangement. These changes in the BlueCard process provide a more timely response from the Home Plan as well as ensure the payment is made directly to the provider rather than the member. Medical Records Blue Plans around the country have made improvements to the medical records process. Medical records can now be sent and received electronically among the Blue Plans. This method significantly reduces the time it takes to transmit supporting documentation, reduces the need to request records multiple times, and reduces the number of lost or misrouted records. When a patient s medical record is necessary for consideration of services, the member s Home Plan will notify Blue Cross and Blue Shield of Alabama. Blue Cross and Blue Shield of Alabama will request the medical record by letter to the provider. Send all medical records for BlueCard claims to Blue Cross and Blue Shield of Alabama rather than directly to the member s Home Plan. All medical records received will be sent to the Home Plan for review. Records that are requested by Blue Cross and Blue Shield of Alabama or records sent additionally for claims review may be sent to the address provided below: Blue Cross and Blue Shield of Alabama Medical Records Attention: ITS Host Department Post Office Box Birmingham, Alabama Note: This address is for BlueCard claims medical records only. All providers are encouraged to submit medical records when requested within 10 days. Prompt responses to these requests for records will enhance the Plan s ability to process claims more timely and efficiently. Under what circumstances may the provider receive a request for medical records for out-of-area members? 1. As part of the pre-authorization process If a request for medical records is received from other Blue Plans prior to rendering services, as part of the pre-authorization process, providers are instructed to submit records directly to the member s Plan that requested them. That is the only circumstances where you would not submit to Blue Cross and Blue Shield of Alabama. 2. As part of a claim review and adjudication These requests come from Blue Cross and Blue Shield of Alabama in a form or a letter requesting specific medical records and including instructions for submission. BlueCard Medical Record Process for Claim Review 1. An initial communication, generally in the form of a letter, is sent to the provider requesting the needed information. 2. A remittance may be received indicating that a claim is being denied pending receipt and review of the patient s record. Occasionally, medical records submitted cross in the mail from the remittance advice or the records may have been ordered from another provider. A remittance advice is not a duplicate request for medical records. If records were previously submitted but received a remittance advice indicating records were needed contact Blue Cross and Blue Shield of Alabama. 3. If a remittance advice is received indicating records are needed but no medical records request was received, contact Blue Cross and Blue Shield of Alabama to determine who submitted the medical record request. 4. Claims are reviewed to determine benefits when the medical record information is received. 14

15 Ways to Assist in Timely Processing of Medical Records 1. If a patient s record is requested following submissions of a claim, forward all requested information to Blue Cross and Blue Shield of Alabama. 2. Follow the specific instructions provided on the request for information, such as a specific address or fax number. 3. Include the request/cover letter when submitting records. 4. Submit information as soon as possible. 5. Only send requested information. 6. Only send information when necessary. Unsolicited claims attachments may cause claim payment delays. Who to Contact with Claims Questions or Issues With the exception of eligibility, benefit and precertification issues, all questions from providers about BlueCard claims and issues should always be directed to the local Plan, Blue Cross and Blue Shield of Alabama. Claims information and status may be accessed through the same electronic means utilized for Blue Cross and Blue Shield of Alabama patients, such as e-practice Management. Blue Cross and Blue Shield of Alabama cannot quote contract benefits for any BlueCard contract belonging to another Plan. Contract specific benefits may be accessed by calling the BlueCard Eligibility number at BLUE (2583). Providers are directed to the member s Home Plan to verify benefits or access benefits and eligibility electronically. Below is a chart to assist in identifying whom to contact: Inquiry Contact Description Verification of Eligibility and Benefits Member s Home Plan Call BLUE (2583), a nationwide eligibility and benefits line, or verify electronically through ProviderAccess on the Web, or through your vendor. Prior Authorizations Member s Home Plan See the back of the member s identification card. Claims Submission Questions Blue Cross and Blue Shield of Alabama Call Provider Customer Service. General Questions Blue Cross and Blue Shield of Alabama Call Provider Customer Service. Status Questions Blue Cross and Blue Shield of Alabama Check electronically through e-practice Management. Inquiry Regarding a Claim Blue Cross and Blue Shield of Alabama Call Provider Customer Service. Claim Rejected for Additional Information Needed Blue Cross and Blue Shield of Alabama Call Provider Customer Service. Overpayments Blue Cross and Blue Shield of Alabama Call Provider Customer Service. Questions about the BlueCard Program and Contractual Obligations Blue Cross and Blue Shield of Alabama Contact your Provider Network Services Representative. Providers interested in participating in e-practice Management or other electronic means of accessing information should contact their electronic claims vendor or Blue Cross and Blue Shield of Alabama s Electronic Data Interchange (EDI) Services area. EDI Services Representatives are responsible for territories within the state. Access our website, for assistance in identifying a provider s EDI Services Representative, or call and ask for a representative. Members should be directed to their Home Blue Cross and Blue Shield Plan for assistance with claim status and payment. The back of their identification cards provides a number for Customer Service. As a rule, other Blue Cross and Blue Shield Plans should not contact providers directly, and contacts from providers should be limited to Blue Cross and Blue Shield of Alabama. The goal of the BlueCard Program is to simplify communication with multiple Plans across the country. 15

16 (Rev ) An Independent Licensee of the Blue Cross and Blue Shield Association