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Provider and Facility Reference Manual

Appendix 2: BlueCard® Program

Introduction

The BlueCard® Program makes filing claims easy.

As a participating provider of Highmark Blue Cross Blue Shield of Western New York you may render services to patients who are national account members of other Blue Plans, and who travel or live in our service area.

This manual is designed to describe the advantages of the program, while providing you with information to make filing claims easy. This manual will offer helpful information about:

  1. Identifying members
  2. Verifying eligibility
  3. Obtaining precertification/preauthorization
  4. Updating your provider information
  5. Filing claims
  6. Who to contact with questions.

Section 1 - What is the BlueCard® Program?

BlueCard is a national program that enables members of one BCBS Plan to obtain health care service benefits while traveling or living in another BCBS Plan’s service area.

The program links participating health care providers with the independent BCBS Plans across the country and in more than 200 countries and territories worldwide through a single electronic network for claims processing and reimbursement.

The program allows you to submit claims for patients from other BCBS Plans, domestic and international, to your local BCBS Plan.

Your local BCBS Plan is your sole contact for claims payment, problem resolution and adjustments.


BlueCard® Program Advantages

The BlueCard Program allows you to conveniently submit claims for members from other BCBS Plans, including international BCBS Plans, directly to Highmark Blue Cross Blue Shield of Western New York. 

Highmark Blue Cross Blue Shield of Western New York will be your one point of contact for all of your claims-related questions.  More than 79,000 other BCBS Plans’ members are currently residing in our service area. Highmark Blue Cross Blue Shield of Western New York continues to experience growth in out-of-area membership because of our partnership with you. That is why we are committed to meeting your needs and expectations. In doing so, your patients will have a positive experience with each visit.


Products included in BlueCard

A variety of products and claim types are eligible to be delivered via BlueCard, however not all Blue Plans offer all of these products to their members. Currently, Highmark Blue Cross Blue Shield of Western New York offers products indicated by the bullets below, however you may see members from other Blue Plans who are enrolled in the other products.

  • Traditional (indemnity insurance)
  • PPO (Preferred Provider Organization)
  • EPO (Exclusive Provider Organization)
  • POS (Point of Service)
  • HMO (Health Maintenance Organization)
  • Medicare Advantage

Accounts Exempt from the BlueCard Program

The following Claims are excluded from the BlueCard Program:

  • Stand-alone Dental
  • Prescription Drugs
  • Vision products delivered through an intermediary model (using a vendor)
  • Claims for the Federal Employee Program (FEP) are exempt from the BlueCard Program; please follow your FEP billing guidelines

Section 2 - How the BlueCard Program Works

BlueCard Access for BlueCard Program

In the example above, a member has PPO coverage through Blue Cross Blue Shield of Tennessee. There are two scenarios where that member might need to see a provider in another Plan’s service area, in this example, Illinois:

  1. if the member was traveling in Illinois or
  2. if the member resided in Illinois and had employer-provided coverage through Blue Cross Blue Shield of Tennessee

In either scenario, the member can obtain the names and contact information for BlueCard PPO providers in Illinois by calling the BlueCard Access Line at 1.800.810.BLUE (2583). The member also can obtain information on the Internet, using the BlueCard National Doctor and Hospital Finder available at bcbs.com.

NOTE: members are not obligated to identify participating providers through either of these methods but it is their responsibility to go to a PPO provider if they want to access PPO in-network benefits.

When the member makes an appointment and/or sees an Illinois BlueCard PPO provider, the provider may verify the member’s eligibility and coverage information via the BlueCard Eligibility Line at 1.800.676.BLUE (2583). The provider also may obtain this information via a HIPAA electronic eligibility transaction if the provider has established electronic connections for such transactions with the local Plan, Blue Cross and Blue Shield of Illinois.

After rendering services, the provider in Illinois files a claim locally with Blue Cross and Blue Shield of Illinois. Blue Cross and Blue Shield of Illinois forward the claim to Blue Cross Blue Shield of Tennessee that adjudicates the claim according to the member’s benefits and the provider’s arrangement with the Illinois Plan. When the claim is finalized, the Tennessee Plan issues an explanation of benefit or EOB to the member, and the Illinois Plan issues the explanation of payment or remittance advice to its provider and pays the provider.

How to Identify Members


Member ID Cards

When members of BCBS Plans arrive at your office or facility, be sure to ask them for their current BCBS Plan membership identification card. 

The main identifier for out of area members is the prefix. The ID cards may also have:

  • PPO in a suitcase logo, for eligible EPO/PPO members
  • Blank suitcase logo
  • An HPN in a suitcase logo with the Blue High Performance Network (HPN) name in the upper right or lower left corner, for Blue HPN EPO members

Important facts concerning member IDs:
 

  • A correct member ID number includes the - prefix (first three positions) and all subsequent characters, up to 17 positions total. This means that you may see cards with ID numbers between 6 and 14 numbers/letters following the prefix.
  • Do not add/delete characters or numbers within the member ID.
  • Do not change the sequence of the characters following the prefix.
  • The prefix is critical for the electronic routing of specific HIPAA transactions to the appropriate Blue Plan.
  • Members who are part of the Federal Employee Program (FEP) will have the letter "R" in front of their member ID number. Claims for these members should also be filed with the local/Host Plan.

Examples of ID Numbers:

Sample of a Membership ID Numbers

As a provider servicing out-of-area members, you may find the following tips helpful:

  • Ask the member for the most current ID card at every visit. Since new ID cards may be issued to members throughout the year, this will ensure you have the most up-to-date information in the member’s file.
  • Make copies of the front and back of the member’s ID card and pass this key information on
    to your billing staff.
  • Remember: Member ID numbers must be reported exactly as shown on the ID card and must not be changed or altered. Do not add or omit any characters from the member ID numbers.

The three-character prefix, at the beginning of the member's identification number, is the key element used to identify and correctly route claims between BCBS Plans. The prefix identifies the BCBS Plan or National Account to which the member belongs. It is critical for confirming a patient's membership and coverage. To ensure accurate claim processing, it is critical to capture all ID card data. If the information is not captured correctly, you may experience a delay with the claim processing. Please make copies of the front and back of the ID card, and pass this key information to your billing staff.

  • Do not make up prefixes.
  • Do not assume that the members ID number is the social security number.  All Blue Plans replaced Social Security numbers on member ID cards with an alternate, unique identifier.

Sample ID Cards

Sample Membership ID Card

BlueCard ID cards have a suitcase logo, it may be an empty suitcase, a PPO in a suitcase, or an HPN in a suitcase.

The PPO in a suitcase logo indicates that the member is enrolled in either a PPO product or an EPO product. In either case, you will be reimbursed according to Highmark Blue Cross Blue Shield of Western New York PPO provider contract. Please note that EPO products may have limited benefits out-of-area.  The potential for such benefit limitations are indicated on the reverse side of an EPO ID card.

The Blue HPN EPO product includes an HPN in a suitcase logo on the ID card.  Members must obtain services from Blue HPN providers to receive full benefits.  If you are a Blue HPN provider, you will be reimbursed for covered services in accordance with your Blue HPN contract with Highmark Blue Cross Blue Shield of Western New York.  If you are not a Blue HPN provider, it’s important to note that benefits for services incurred with non – Blue HPN providers are limited to emergent care within Blue HPN product areas, and to urgent and emergent care outside of Blue HPN product areas.  For these limited benefits, if you are a PPO provider, you will be reimbursed according to Highmark Blue Cross Blue Shield of Western New York PPO provider contract, just like you are for other EPO products.

The empty suitcase logo indicates that the member is enrolled in one of the following products: Traditional, HMO or POS. For members having traditional coverage, you will be reimbursed according to Highmark Blue Cross Blue Shield of Western New York traditional provider contract. For members who have HMO and POS coverage, you will be reimbursed according to Highmark Blue Cross Blue Shield of Western New York Managed Care provider contract.

Some BCBS ID cards don’t have any suitcase logo on them, such as the ID cards for Medicaid, State Children’s Health Insurance Programs (SCHIP) if administered as part of State’s Medicaid, and Medicare Complementary and Supplemental products, also known as Medigap. Government-determined reimbursement levels apply to these products. While Highmark Blue Cross Blue Shield of Western New York routes all of these claims for out-of-area members to the member’s BCBS  Plan, most of the Medicare Complementary or Medigap claims are sent directly from the Medicare intermediary to the member’s BCBS Plan via the established electronic Medicare crossover process.

How to Identify BlueCard Blue HPN Members

Blue High Performance Network (Blue HPN) is a narrow network that is available to members that live in key metropolitan areas.  Blue HPN members must access Blue HPN providers in order to receive full benefits.  If you are a Blue HPN provider, you will be reimbursed for services provided to Blue HPN members according to the Blue HPN contract with the Highmark Blue Cross Blue Shield of Western New York.  If you are not a Blue HPN provider, it’s important to note that benefits for services incurred with non – Blue HPN providers are limited to emergent care within Blue HPN product areas, and to urgent and emergent care outside of Blue HPN product areas.

You can recognize Blue HPN members by the following:

  • The Blue High Performance Network name on the front of the member ID card
  • The HPN in a suitcase logo in the bottom right hand corner of the member ID card
Language regarding benefit limitations is also included on the back of the Blue HPN EPO member ID card.  For these limited benefits, if you not a Blue HPN provider but are a PPO provider you will be reimbursed according to Blue Cross Blue Shield of Western New York PPO provider contract, just like you are for the other EPO products.

Sample ID Card

How to Identify BlueCard Managed Care/POS Members

 

The BlueCard Managed Care/POS program is for members who reside outside their BCBS Plan’s service area. Unlike the BlueCard PPO Program, the BlueCard Managed Care/POS program, members are enrolled in Highmark Blue Cross Blue Shield of Western New York network and have a primary care physician (PCP). You can recognize BlueCard Managed Care/ POS  members who are enrolled in Highmark Blue Cross Blue Shield of Western New York network through the member ID card as you do for all other BlueCard members. The ID cards will include:

 

  • A local network identifier
  • The three-character prefix at the beginning of the member’s ID number
  • The blank suitcase logo

For members who participate in the BlueCard POS coverage, you will be reimbursed according to Highmark Blue Cross Blue Shield of Western New York POS provider contract. 

Sample ID Card

How to Identify International Members

Occasionally, you may see identification cards from members of International Licensees or that are for international-based products.  Currently, those Licensees include Blue Cross Blue Shield of the U.S. Virgin Islands, Blue Cross & Blue Shield of Uruguay, Blue Cross and Blue Shield of Panama, Blue Cross Blue Shield of Costa Rica, and those products include those provided through GeoBlue and the Blue Cross Blue Shield Global portfolio; however, if in doubt, always check with Highmark Blue Cross Blue Shield of Western New York as the list of International Licensees and products may change. ID cards from these Licensees and for these products will also contain three-character prefixes and may or may not have one of the benefit product logos referenced in the following sections. Please treat these members the same as you would domestic BCBS Plan members (e.g., do not collect any payment from the member beyond cost-sharing amounts such as deductible, coinsurance and co-payment) and file their claims to Highmark Blue Cross Blue Shield of Western New York. See below for sample ID cards for international members and products.

Example of an ID card from an International Licensee:

Blue Cross & Blue Shield de Uruguay International Products ID Card

Examples of ID cards for International Products
Illustration A - GeoBlue:

GeoBlue sample id card

Illustration B – Blue Cross Blue Shield Global Core portfolio:

Blue Cross Blue Shield Global Member ID Card

Illustration C – Shield-only ID Card:

Please note: in certain territories, including Hong Kong and the United Arab Emirates, Blue Cross branded products are not available. The ID cards of members in these territories will display the Blue Shield Global Core logo (see example below):

Blue Shield Global Member ID Card

Canadian ID Cards

Please note that the Canadian Association of Blue Cross Plans and its member plans are separate and distinct from the Blue Cross and Blue Shield Association (BCBSA) and its member Plans in the United States.

You may occasionally see ID cards for people who are covered by a Canadian Blue Cross plan. Claims for Canadian Blue Cross plan members are not processed through the BlueCard® Program.

Please follow the instructions of the Blue Cross plans in Canada and those, if any, on the ID cards for servicing their members. The Blue Cross plans in Canada are:

  • Alberta Blue Cross
  • Manitoba Blue Cross
  • Medavie Blue Cross
  • Ontario Blue Cross
  • Pacific Blue Cross 
  • Quebec Blue Cross
  • Saskatchewan Blue Cross

Consumer Directed Health Care and Health Care Debit Cards

Consumer Directed Health Care (CDHC) is a term 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 Consumer Directed Health Care (CDHC) plans often have healthcare debit cards that allow them to pay for out-of-pocket costs using funds from their Health Reimbursement Arrangement (HRA), Health Savings Account (HSA) or Flexible Spending Account (FSA). All three are types of tax favored accounts offered by the member’s employer to pay for eligible expenses not covered by the health plan.

Some cards are “stand-alone” debit cards that cover eligible out-of-pocket costs, while others also serve as a health plan member ID card. These debit cards can help you simplify your administration process and can potentially help:

  • Reduce bad debt
  • Reduce paperwork for billing statements
  • Minimize bookkeeping and patient account functions for handling cash and checks
  • Avoid unnecessary claim payment delays

In some cases, the card will display the Blue Cross and Blue Shield trademarks, along with the logo from a major debit card such as MasterCard® or Visa®.

Below is a sample stand-alone health care debit card:

sample ID card

Below is a sample combined health care debit card and member ID card:

sample ID card

The cards include a magnetic strip allowing providers to swipe the card to collect the member’s cost-sharing amount (i.e., copayment). With healthcare debit cards, members can pay for copayments and other out-of-pocket expenses by swiping the card though any debit card swipe terminal. The funds will be deducted automatically from the member’s appropriate HRA, HSA or FSA account.

If your office currently accepts credit card payments, there is no additional cost or equipment necessary. The cost to you is the same as what you pay to swipe any other signature debit card.

Helpful Tips:

  • Using the member’s current member ID number, including prefix, carefully determine the member’s financial responsibility before processing payment. Check eligibility and benefits electronically through Highmark Blue Cross Blue Shield of Western New York or by calling 1.800.676.BLUE (2583).
  • All services, regardless of whether or not you’ve collected the member responsibility at the time of service, must be billed to Highmark Blue Cross Blue Shield of Western New York or proper benefit determination, and to update the member’s claim history.
  • Please do not use the card to process full payment up front.  If you have any questions about the member’s benefits, please contact 1.800.676.BLUE (2583) or, for questions about the health care debit card processing instructions or payment issues, please contact the toll-free debit card administrator’s number on the back of the card.

Limited Benefit Products  

Verifying BCBS patients’ benefits and eligibility is important, now more than ever since new products and benefit types entered the market.  Patients who have traditional Blue PPO, HMO, POS, or other coverage, typically with high lifetime coverage limits i.e. ($1million or more), may have annual benefits are limited to $50,000 or less.

Currently Highmark Blue Cross Blue Shield of Western New York doesn’t offer such limited benefit plans to our members, however you may see patients with limited benefits who are covered by another BCBS Plan.  

How to recognize members with limited benefits products?

Members with Blue limited benefits coverage (that is, annual benefits limited to $50,000 or less) carry ID cards that may have one or more of the following indicators:

  • Product name will be listed such as InReach or MyBasic
  • A green stripe at the bottom of the card
  • A statement either on the front or the back of the ID card stating this is a limited  benefits product
  • A black cross and/or shield to help differentiate it from other identification cards

These ID cards may look like this:

Blue Cross Blue Shield Global Member ID Card

How to find out if the patient has limited benefit coverage?

You may do so electronically by submitting HIPAA 270 eligibility inquiry to Highmark Blue Cross Blue Shield of Western New York or via an Electronic Data Interchange (EDI) transaction or 1.800.676.BLUE (2583) eligibility line for out-of-area members.

Both electronically and via phone, you will receive patient’s accumulated benefits to help you understand the remaining benefits left for the member.

  • Tips:  In addition to obtaining a copy of the member’s ID card, regardless of the benefit product type, always verify eligibility and benefits electronically with Highmark Blue Cross Blue Shield of Western New York or by calling 1-800-676-BLUE (2583). You will receive the member’s accumulated benefits to help you understand his/her remaining benefits.
  • If the cost of service extends beyond the member’s benefit coverage limit, please inform your patient of any additional liability he/she might have.
  • If you have questions regarding a BCBS Plan’s limited benefits ID card/product, please contact The number on the members ID card
     

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 are member’s liability.

We recommend that you inform the patient of any potential liability they might have as soon as possible.


Who do I contact if I have additional questions about Limited Benefit Plans?

If you have any questions regarding any other BCBS Plans’ Limited Benefits products, contact Highmark Blue Cross Blue Shield of Western New York at 1-800-444-2012.
 

Reference Based Benefits

With health care costs increasing, employers are considering alternative approaches to control health care expenses by placing a greater emphasis on employee accountability by encouraging members to take a more active role while making health care decisions.  Plans have begun to introduce Reference Based Benefits, which limit certain (or specific) benefits to a dollar amount that incentivizes members to actively shop for health care for those services.

The goal of Reference Based Benefits is to have members engage in their health choices by giving them an incentive to shop for cost effective providers and facilities.  Reference Based Benefit designs hold the member responsible for any expenses above a calculated “reference cost” ceiling for a single episode of service.  Due to the possibility of increased member cost sharing, Reference Based Benefits will incent members to use Plan transparency tools, like the National Consumer Cost Tool (NCCT), to search for and identify services that can be performed at cost effective providers and/or facilities that charge at or below the reference cost ceiling.

How do reference-based benefits work?

Reference-based benefits are a new benefit feature where the plan will pay up to a pre-determined amount for specific procedures called a “reference cost.”  If the allowed amount exceeds the reference cost, that excess amount becomes the members’ responsibility.


How are reference costs established?

The reference costs are established for an episode of care based on claims data received by Highmark Blue Cross Blue Shield of Western New York from providers in your area.


How will I get paid?

Reference Based Benefits will not modify the current contracting amount agreed on between you and Blue Cross Blue Shield of Western New York.  Providers can expect to receive their contract rate on all procedures where Reference Based Benefits apply.

  • Example 1: If a member has a reference cost of $500 for an MRI of the spine and the allowable amount is $700, then Highmark Blue Cross Blue Shield of Western New York will pay up to the $500 for the procedure and the member is responsible for the $200.
  • Example 2: If a member has a reference cost ceiling of $600 for a CT scan of the Head/Brain and allowable amount is $400, then Highmark Blue Cross Blue Shield of Western New York will pay up to the $400 for the procedure.


How much will the member be responsible for out-of-pocket?

When reference-based benefits are applied and the cost of the services rendered is less than the reference cost ceiling, then Highmark Blue Cross Blue Shield of Western New York will pay eligible benefits as it has in the past; while the member continues to pay their standard cost sharing amounts in the forms of: co-insurance, co-pay, or deductible as normal.

If the cost of the services rendered exceeds the reference cost ceiling, then Highmark Blue Cross Blue Shield of Western New York will pay benefits up to that reference cost ceiling, while the member continues to pay their standard cost sharing amounts in the forms of: co-insurance, co-pay, or deductible; as well as any amount above the reference cost ceiling up to the contractual amount.


How will I be able to identify if a member is covered under reference-based benefits?

When you receive a response from a benefits and eligibility inquiry, you will be notified if a member is covered under reference-based benefits.

Additionally, you can call the Blue Eligibility number (1-800-676-BLUE(2583) to verify if a member is covered under reference-based benefits.

Do I need to do anything differently if a member is covered under reference-based benefits?

While there are no additional steps that you need to take, you may want to verify the reference cost maximum prior to performing a procedure covered under Reference Based Benefits.  You can check if reference-based benefits apply to professional and facility charges for the member, by submitting an electronic benefits and eligibility inquiry to your local BCBS Plan. Alternatively, you can contact the member’s Plan by calling the Blue Eligibility number 1-800-676-BLUE (2583).


Do reference-based benefits apply to emergency services?

No.  Reference-based benefits are not applicable to any service that is urgent or emergent.


Do reference-based benefits apply to benefits under the Affordable Care Act essential health benefits?

Yes.  Health plans must offer products at the same actuarial value to comply with the Affordable Care Act legislative rules.


How does the member identify services at or below the reference cost?

Members with reference-based benefits use consumer transparency tools to determine if a provider will deliver the service for less than the reference cost.


How will the reference-based benefits cost apply to professional and facility charges?

For more information on how reference-based benefits will apply costs to the professional and facility charges, please submit an electronic benefits and eligibility inquiry to the member’s local Blue plan. If you have additional questions, you can contact the Blue Eligibility number 1-800-676-BLUE(2583) for the member you are seeing.


What if a member covered under reference-based benefits asks for additional information about their benefits?

Since members are subject to any charges above the reference cost up to the contractual amount for particular services, members may ask you to estimate how much a service will cost. 

Also, you can direct members to view their BCBS Plans transparency tools to learn more about the cost established for an episode of care.


What procedures are covered under reference-based benefits?

The following procedures will be covered under reference-based benefits:
* Applicable services may vary by employer group.


Where do I submit the claim?

You should submit the claim to Highmark Blue Cross Blue Shield of Western New York under your current billing practices.

How will reference-based benefits be shown on a payment remittance?

When you receive payment for services the claim will pay per the member’s benefits with any amount over the reference cost being applied to the benefit maximum.


Is there anything different that I need to submit with member claims?

No.  You should continue to submit your claims as you previously have to Highmark Blue Cross Blue Shield of Western New York.


Who do I contact if I have a question?


If you have any questions regarding the reference-based benefits, please contact Highmark Blue Cross Blue Shield of Western New York at 1-800-444-2012.


Coverage and Eligibility Verification

For other BCBS Plans’ members, submit an electronic inquiry through Highmark Blue Cross Blue Shield of Western New York, HEALTHeNET or call BlueCard Eligibility 1-800-676-BLUE (2583) to verify the patient’s eligibility and coverage.

Electronic: Log on to HEALTHeNET- Submit a HIPAA 270 transaction (eligibility)

You can receive real-time responses to your eligibility requests for out-of-area members between 6 a.m. and midnight, Eastern Time, Monday through Saturday.

  •  NOTE: PROVIDERS ARE ENCOURAGED TO VERIFY ELIGIBLITY ELECTRONICALLY VIA THE HIPAA 270 TRANSACTION

Phone: Call BlueCard Eligibility 1-800-676-BLUE (2583)

  1. English and Spanish speaking phone operators are available to assist you.
  2. BCBS Plans are located throughout the country and may operate on a different time schedule than Highmark Blue Cross Blue Shield of Western New York... You may be transferred to a voice response system linked to customer enrollment and benefits outside that Plan’s regular business hours.
  3. The BlueCard. Eligibility line is for eligibility, benefit and precertification/referral authorization inquiries only. It should not be used for claim status. See Claim Filing section for claim filing information.

Eligibility and Benefits for Blue HPN EPO Members:

Blue HPN EPO members will be identified as such on the HIPPA 271 transaction from Highmark Blue Cross Blue Shield of Western New York.  If you are a Blue HPN provider, you should look for the in-network cost share on the HIPAA 271 response.  If you are not a Blue HPN provider, you should be aware that the only services that are covered for Blue HPN EPO members are emergent care within Blue HPN product areas and urgent and emergent care outside of Blue HPN product areas.  All other services are considered out-of-network, which will be indicated with a 100% member cost share on the HIPAA 271 transaction.

Most Blue HPN members will have the HPN without Tiers version of the Blue HPN product and this will be indicated on the HIPAA 271 transaction.  Some members will have the PHN with Tiers version of the Blue HPN product and these members will have an in-network benefit and a Tier 2 benefit.  For these members, Tier 2 benefits only apply to Blue HPN providers in the New Jersey and Philadelphia Blue HPN product areas.  If you are a Blue HPN provider that is not located in either the New Jersey or Philadelphia Blue HPN product area, you should ignore the Tier 2 benefit on the HIPAA 271 transaction.

Electronic Health ID Cards

Some local BCBS Plans have implemented electronic health ID cards to facilitate a seamless coverage and eligibility verification process.

  • Electronic health ID cards enables electronic transfer of core subscriber/member data from the ID card to the provider's system.
  • A Blue electronic health ID card has a magnetic stripe on the back of the ID card, similar to what you can find on the back of a credit or debit card.  The subscriber/member electronic data is embedded on the third track of the three-track magnetic stripe.
  • Core subscriber/member data elements embedded on the third track of the magnetic stripe include:  subscriber/member name, subscriber/member ID, subscriber/member date of birth and Plan ID.
  • The Plan ID data element identifies the health plan that issued the ID card.  Plan ID will help providers facilitate health transactions among various payers in the market place.
  • Providers will need a track 3 card reader in order for the data on track 3 of the magnetic stripe to be read (the majority of card readers in provider offices only read tracks 1 & 2 of the magnetic stripe; tracks 1 & 2 are proprietary to the financial industry).

Sample of electronic health ID card:

Blue Shield Global Member ID Card

Utilization Review

You should remind patients that they are responsible for obtaining precertification/ preauthorization for out-patient services from their BCBS Plan. Participating providers are responsible for obtaining pre-service review for inpatient facility services when the services are required by the account or member contract. In addition, members are held harmless when pre-service review is required and not received for inpatient facility services (unless an account receives an approved exception).

Providers must follow specified timeframes for pre-service review notifications:

  • 48 hours to notify the member’s Plan of change in pre-service review
  • 72 hours for emergency/urgent pre-service review notification.

General information on precertification/preauthorization information can be found on the Out-of-Area member Medical Policy and Preauthorization/Precertification Router, utilizing the prefix found on the member ID card.

You may contact the member’s plan by calling the number on the back of their card, or:

  • Call BlueCard Eligibility 1.800.676.BLUE (2583)—ask to be transferred to the utilization review area.
  • When precertification/preauthorization for a specific member is handled separately from eligibility verifications at the member’s BCBS Plan, your call will be routed directly to the area that handles precertification/pre-authorization. You will choose from four options depending on the type of service for which you are calling:
    • Medical/Surgical
    • Behavioral Health
    • Diagnostic Imaging/Radiology
    • Durable/Home Medical Equipment (D/HME)

If you are inquiring about both, eligibility and precertification/preauthorization through 1-800-676-BLUE (2583), your eligibility inquiry will be addressed first.  Then you will be transferred, as appropriate, to the precertification/preauthorization area.

  • Submit an electronic HIPAA 278 transaction (referral/authorization) to Highmark Blue Cross Blue Shield of Western New York, HEALTHeNET
  • The member’s Blue Plan may contact you directly regarding clinical information and medical records prior to treatment or for concurrent review or disease management for a specific member.

When obtaining precertification/preauthorization, please provide as much information as possible, to minimize potential claims issues. Providers are encouraged to follow-up immediately with a member’s BCBS Plan to communicate any changes in treatment or setting to ensure existing authorization is modified or a new one is obtained, if needed.  Failure to obtain approval for the additional days may result in claims processing delays and potential payment denials.

Electronic Provider Access

Electronic Provider Access (EPA) gives providers the ability to access out-of-area member’s BCBS Plan provider portals to conduct electronic pre-service review. The term pre-service review is used to refer to pre-notification, precertification, preauthorization and prior approval, amongst other pre-claim processes. Electronic Provider Access (EPA) enables providers to use their local BCBS Plan provider portal to gain access to an out-of-area member’s BCBS Plan provider portal, through a secure routing mechanism. Once in the BCBS Plan provider portal, the out-of-area provider has the same access to electronic pre-service review capabilities as the Plan’s local providers.

The availability of EPA varies depending on the capabilities of each BCBS Plan. Some Plans have electronic pre-service review for many services, while others do not. The following describes how to use EPA and what to expect when attempting to contact BCBS Plans.

Using the EPA Tool

The first step for providers is to go to bcbswny.com

Menu option: For Providers, Bluecard, Out- of –Area Policy Search

Next, enter the prefix from the member’s ID card. The prefix is the first three characters that precede the member id.

Note:  You can first check whether precertification is required by the BCBS Plan by either:  

  1. Sending a service-specific request through Blue Exchange.
  2. Accessing the BCBS Plan’s precertification requirements pages by using the medical policy router:

Entering the member’s prefix from the ID card automatically routes you to the Home Plan EPA landing page. This page welcomes you to the Plan’s portal and indicates that you have left Highmark Blue Cross Blue Shield of Western New York portal. The landing page allows you to connect to the available electronic pre-service review processes. Because the screens and functionality of Plans’ pre-service review processes vary widely, Plans may include instructional documents or e-learning tools on the landing page to provide instruction on how to conduct an electronic pre-service review. The page also includes instructions for conducting pre-service review for services where the electronic function is not available.

The BCBS Plan landing page looks similar across Plans, but will be customized to the particular Plan based on the electronic pre-service review services they offer.

Provider Financial Responsibility for Pre-Service Review for BlueCard Members

Highmark Blue Cross Blue Shield of Western New York participating providers are responsible for obtaining pre-service review for inpatient facility services for BlueCard® members and holding the member harmless when pre-service review is required by the account or member contract and not received for inpatient services.  Participating providers must also:

  • Notify the member’s BCBS Plan within 48 hours when a change or modifications to the original pre-service review occurs.
  • Obtain pre-service review for emergency and/or urgent admissions within 72 hours.

Failure to contact the member’s BCBS Plan for pre-service review or for a change or modification of the pre-service review, may cause the claim to deny for inpatient facility services. The member must be held harmless and cannot be balance-billed if pre-service review has not occurred.

Pre-service review contact information for a member’s BCBS Plan is provided on the member’s identification card. Pre-service review requirements can also be determined by:

  • Using the Electronic Provider Access (EPA) tool available at Highmark Blue Cross Blue Shield of Western New York provider at bcbswny.com Note: the availability of EPA will vary depending on the capabilities of each member’s BCBS Plan. Submitting an ANSI 278 electronic transaction to Highmark Blue Cross Blue Shield of Western New York or calling 1.800.676.BLUE (2583).

Services that deny as not medically necessary remain member liability.

Who do I contact if I have additional questions on provider financial responsibility from pre-service review?

If you have any questions on Provider Financial Responsibility or general questions, please call Highmark Blue Cross Blue Shield of Western New York at 1-800-444-2012.

Who do I contact if I have additional questions about Electronic Provider Access?

Highmark Blue Cross Blue Shield of Western New York 1-800-666-4627

*Unless the member signed a written consent to be billed prior to the rendering service.

Updating Your Provider Information

Maintaining accurate provider information is critically important to ensure the consumers have timely access to care. Updated information helps us maintain accurate provider directories and also ensures that providers are more easily accessible to members. Additionally, Plans are required by Centers for Medicare and Medicaid Services (CMS) to include accurate information in provider directories for certain key provider data elements and accuracy of directories are routinely reviewed/audited by CMS.

Since it is the responsibility of each provider to inform Plans when there are changes, providers are reminded to notify Highmark Blue Cross Blue Shield of Western New York of any changes to their demographic information or other key pieces of information, such a change in their ability to accept new patients, street address, phone number or any other change that affects patient access to care. For Highmark Blue Cross Blue Shield of Western New York to remain compliant with federal and state requirements, changes must be communicated to us minimally 30 days prior to the change, or as soon as possible so that members have access to the most current information in the Provider Directory.

Key Data Elements

The data elements required by CMS and crucial for member access to care are as follows:

  • Physician Name
  • Location, e.g., address, suite city/state, zip code
  • Phone Number
  • Accepting new patient status
  • Hospital affiliations
  • Medical group affiliations

Plans are also encouraged (and in some cases required by certain regulatory/accrediting entities) to include accurate information for the following data elements:

  • Physician gender
  • Languages spoken
  • Office hours
  • Specialties
  • Physical disabilities accommodations, e.g., wide entry, wheelchair access, accessible exam rooms and tables, lifts, scales, bathrooms and stalls, grab bars, other accessible equipment
  • Indian Health Service Status
  • Licensing Information, i.e., medical license number, license state, national provider number
  • Provider credentials, i.e., board certification, place of residency, internship, medical school, year of graduation
  • Email and website address
  • Hospital has an emergency department, if applicable

How to update your information

You should routinely check your current practice information by visiting our Find A Doctor tool.  If your information is not correct and updates are needed, please provide the correct information as soon as possible by completing a Provider Demographic Change Form on our forms page.

Section 3 - Claim Filing

How Claims Flow through BlueCard

Below is an example of how claims flow through BlueCard

flow chart of claims

After the member of another Blue Plan receives services from you, you should file the claim with Highmark Blue Cross Blue Shield of Western New York. We will work with the member’s Plan to process the claim and the member’s Plan will send an explanation of benefit or EOB to the member.  We will send you an explanation of payment or the remittance advice and issue the payment to you under the terms of our contract with you and based on the members benefits and coverage.

Following these helpful tips will improve your claim experience:

  • Ask members for their current member ID card and regularly obtain new photocopies of it (front and back). Having the current card enables you to submit claims with the appropriate member information (including prefix) and avoid unnecessary claims payment delays. 
  • Check eligibility and benefits electronically at HEALTHeNET or by calling 1.800.676.BLUE (2583). Be sure to provide the member’s prefix. 
  • Verify the member’s cost sharing amount before processing payment. Please do not process full payment upfront.
  • Indicate any payment you collected from the patient on the claim. (On the 837 electronic claim submission form, check field AMT01=F5 patient paid amount; on the CMS1500 locator 29 amount paid; on UB92 locator 54 prior payment; on UB04 locator 53 prior payment.) 
  • Submit all BlueCard® claims to Highmark Blue Cross Blue Shield of Western New York. Be sure to include the member's complete identification number when you submit the claim. This includes the three-character prefix. Submit claims with only valid prefixes; claims with incorrect or missing prefixes and member identification numbers cannot be processed.
  • In cases where there is more than one payer and a BCBS Plan is a primary payer, submit Other Party Liability (OPL) information with the BCBS claim. Upon receipt, Highmark Blue Cross Blue Shield of Western New York will electronically route the claim to the member's BCBS plan. The member's plan then processes the claim and approves payment.
  • Highmark Blue Cross Blue Shield of Western New York will reimburse you for services. 
  • Do not send duplicate claims. Sending another claim, or having your billing agency resubmit claim automatically, actually slows down the claims payment process and creates confusion for the member.
  • To check claim status, contact Highmark Blue Cross Blue Shield of Western New York at 1-800-444-2012 or submit an electronic HIPAA 276 transaction (claim status request) to HEALTHeNET.

Medicare-Related Claims – Refer to bcbswny.com BlueCard Section  


Medicare Advantage Overview

"Medicare Advantage” (MA) is the program alternative to standard Medicare Part A and Part B fee-for-service coverage; generally referred to as “traditional Medicare.”

MA offers Medicare beneficiaries several product options (similar to those available in the commercial market), including health maintenance organization (HMO), preferred provider organization (PPO), point-of-service POS and private fee-for-service (PFFS) plans.

All Medicare Advantage plans must offer beneficiaries at least the standard Medicare Part A and B benefits, but many offer additional covered services as well (e.g., enhanced vision and dental benefits).

In addition to these products, Medicare Advantage organizations may also offer a Special Needs Plan (SNP), which can limit enrollment to subgroups of the Medicare population in order to focus on ensuring that their special needs are met as effectively as possible.

Medicare Advantage plans may allow in- and out-of-network benefits, depending on the type of product selected. Providers should confirm the level of coverage (by calling 1.800.BLUE (2583) or submitting an electronic inquiry) for all Medicare Advantage members prior to providing service since the level of benefits, and coverage rules, may vary depending on the Medicare Advantage plan.

Types of Advantage Plans


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 a network of physicians and hospitals. Generally (except in urgent or emergency care situations), medical services are only covered when provided by in-network providers. The level of benefits and the coverage rules may vary by Medicare Advantage plan.

Medicare Advantage POS

A Medicare Advantage POS program is an option available through some Medicare HMO programs. It allows members to determine — at the point of service — whether they want to receive certain designated services within the HMO system, or seek such services outside the HMO’s provider network (usually at greater cost to the member). The Medicare Advantage POS plan may specify which services will be available outside of the HMO’s provider network.

Medicare Advantage PPO

A Medicare Advantage PPO is a plan that has a network of providers, but unlike traditional HMO products, it allows members who enroll 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 may be offered on a local or regional (frequently multi-state) basis. Special payment and other rules apply to regional PPOs.

Blue Medicare Advantage PPO members have in-network access to Blue MA PPO providers.

Medicare Advantage PFFS

A Medicare Advantage PFFS plan is a plan in which the member may go to any Medicare-approved doctor or hospital that accepts the plan’s terms and conditions of participation. Acceptance is “deemed” to occur where the provider is aware, in advance of furnishing services, that the member is enrolled in a PFFS product and where the provider has reasonable access to the terms and conditions of participation.

The Medicare Advantage Organization, rather than the Medicare program, pays for services rendered to such members. Members are responsible for cost-sharing, as specified in the plan, and balance billing may be permitted in limited instance where the provider is a network provider and the plan expressly allows for balance billing.

Medicare Advantage PFFS varies from the other Blue products you might currently participate in:

  • You can see and treat any Medicare Advantage PFFS member without having a contract with Highmark Blue Cross Blue Shield of Western New York.
  • If you do provide services, you will do so under the Terms and Conditions of that member’s Blue Plan.
  • MA PFFS Terms and Conditions might vary for each Blue Plan and we advise that you review them before servicing MA PFFS members. 
  • Please refer to the back of the member’s ID card for information on accessing the Plan’s Terms and Conditions. You may choose to render services to a MA PFFS member on an episode of care (claim-by-claim) basis.
  • Submit your MA PFFS claims to Highmark Blue Cross Blue Shield of Western New York.

Medicare Advantage Medical Savings Account (MSA)

Medicare Advantage Medical Savings Account (MSA) is a Medicare health plan option made up of two parts. One part is a Medicare 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.


Medicare Advantage PPO Network Sharing


What is BCBS Medicare Advantage PPO Network Sharing?

All Blue Cross Blue Shield Medicare Advantage PPO Plans participate in reciprocal network sharing. This network sharing allows all Blue Cross Blue Shield MA PPO members to obtain in-network benefits when traveling or living in the service area of any other Blue Cross Blue Shield MA PPO Plan as long as the member sees a contracted MA PPO provider.

What does the BCBS Medicare Advantage (MA) PPO Network Sharing mean to me?

If you are a contracted MA PPO provider with Highmark Blue Cross Blue Shield of Western New York  and you see MA PPO members from other Blue Cross Blue Shield Plans, these members will be extended the same contractual access to care and will be reimbursed in accordance with your negotiated rate with your Highmark Blue Cross Blue Shield of Western New York contract. These members will receive in-network benefits in accordance with their member contract.

If you are not a contracted MA PPO provider with Blue Cross and Blue Shield of Western New York and you provide services for any Blue Cross Blue Shield Medicare Advantage members, you will receive the Medicare allowed amount for covered services. For urgent or emergency care, you will be reimbursed at the member’s in-network benefit level. Other services will be reimbursed at the out-of-network benefit level.

How do I recognize an out-of-area member from one of these plans participating in the Blue Cross Blue Shield MA PPO network sharing?

You can recognize a Medicare Advantage member when their Blue Cross Blue Shield member ID card has the following logo:

The “MA” in the suitcase indicates a member who is covered under the MA PPO network sharing program. Members have been asked not to show their standard Medicare ID card when receiving services; instead, members should provide their Blue Cross and/or Blue Shield member ID.

Do I have to provide services to Medicare Advantage PPO members from other Blue Cross Blue Shield plans?

If you are a contracted Medicare Advantage PPO provider with Highmark Blue Cross Blue Shield of Western New York you must provide the same access to care as you do for out of area Blue Cross Blue Shield of Western New York MA PPO members. You can expect to receive the same contracted rates for such services.

If you are not a Medicare Advantage PPO contracted provider, you may see Medicare Advantage members from other Blue Cross Blue Shield Plans but you are not required to do so. Should you decide to provide services to Blue Cross Blue Shield Medicare Advantage members, you will be reimbursed for covered services at the Medicare allowed amount based on where the services were rendered and under the member’s out-of-network benefits. For urgent or emergency care, you will be reimbursed at the in-network benefit level.

What if my practice is closed to new local Blue Cross Blue Shield Medicare Advantage PPO members?

If your practice is closed to new local Blue Cross Blue Shield MA PPO members, you do not have to provide care for Blue Cross Blue Shield MA PPO out-of-area members. The same contractual arrangements apply to these out-of-area network sharing members as your local MA PPO members.

 

What will I be paid for providing services to Medicare Advantage out-of-area members not participating in the Medicare Advantage PPO Network Sharing?

If you are a MA PPO contracted provider with Highmark Blue Cross Blue Shield of Western New York, benefits will be based on your contracted MA PPO rate for providing covered services to MA PPO members form any MA PPO Plan.  Once you submit the MA claim, Highmark Blue Cross Blue Shield of Western New York will work with the other Plan to determine benefits and send you the payment.

When you provide covered services to other BCBS MA out-of-area members’, benefits will be based on the Medicare allowed amount.  Once you submit the claim, Highmark Blue Cross Blue Shield of Western New York will send you the payment.  However, these services will be paid under the member’s out-of-network benefits unless for urgent or emergency care.

May I request payment upfront?

Generally, once the member receives care, you should not ask for full payment up front other than out-of-pocket expenses (deductible, co-payment, coinsurance and non-covered services)

Under certain circumstances when the member has been notified in advance that a service will not be covered, you may request payment from the member before service are rendered or billed to the member.  The member should sign a Advance Benefit Notification (ABN) from before services are rendered in these situations.

What is the member cost sharing level and co-payments?

Member cost sharing level and co-payment is based on the member’s health plan.  You may collect the co-payment amounts from the member at the time of service. To determine the cost sharing and/or co-payment amounts, you should call the Eligibility Line at 1.800.676.BLUE (2583).

May I balance bill the member the difference in my charge and the allowance?

No, you may not balance bill the member for this difference. Members may be billed for any deductibles, coinsurance, and/or copays.

 What if I disagree with the reimbursement amount I received?

If there is a question concerning the reimbursement amount, contact your local plan at 1-800-444-2012.

Who do I contact if I have a question about MA PPO network sharing?

If you have any questions regarding the MA program or products, contact Highmark BCBSWNY at: 1-800-444-2012.

What is Blue Cross Blue Shield Medicare Advantage PPO Network Sharing?

Network sharing allows MA PPO members from MA PPO Blue Cross Blue Shield Plans to obtain in-network benefits when traveling or living in the service areas of the MA PPO Plans as long as the member sees a contracted Medicare Advantage PPO provider. Medicare Advantage PPO shared networks are available in 39 states and one territory:

Medicare Advantage Claims Submission

  • Submit all Medicare Advantage claims to Highmark Blue Cross Blue Shield of Western New York
  • Do not bill Medicare directly for any services rendered to a Medicare Advantage member.
  • Payment will be made directly by a Blue Cross Blue Shield Plan.

Reimbursement for Medicare Advantage PPO, HMO, POS, PFFS

Note to Provider: The reimbursement information below applies when a provider treats a Blue Cross Blue Shield Medicare Advantage member to whom the provider’s contract does not apply.  

Examples:

  • A provider that is contracted for Medicare Advantage PPO business treats a Medicare Advantage HMO member.
  • A provider that is contracted for commercial business only treats a MA PPO member.
  • A provider that is contracted for Medicare Advantage HMO business treats any MA PPO member.
  • A provider that is contracted for local Medicare Advantage HMO business treats an out-of-area MA HMO member.
  • A provider that is not contracted with the local Plan treats a MA HMO member.

Based upon the Centers for Medicare and Medicaid Services (CMS) regulations, if you are a provider who accepts Medicare assignment and you render services to a Medicare Advantage member for whom you have no obligation to provide services under your contract with a Blue Cross Blue Shield Plan, you will generally be considered a non-contracted provider and be reimbursed the equivalent of the current Medicare allowed amount for all covered services (i.e., the amount you would collect if the beneficiary were enrolled in traditional Medicare).

Special payment rules apply to hospitals and certain other entities (e.g., skilled nursing facilities) that are non-contracted providers.

Providers should make sure they understand the applicable Medicare Advantage reimbursement rules.

Providers that are paid on a reasonable cost basis under Original Medicare should send their CMS Interim Payment Rate letter with their Medicare Advantage claim.  This letter will be needed by the Plan to calculate the Medicare Allowed amount.

Other than the applicable member cost sharing amounts, reimbursement is made directly by a Blue Cross Blue Shield Plan or its branded affiliate. In general, you may collect only the applicable cost sharing (e.g., co-payment) amounts from the member at the time of service, and may not otherwise charge or balance bill the member.

NOTE: Enrollee payment responsibilities can include more than copayments (e.g., deductibles).

Please review the remittance notice concerning Medicare Advantage plan payment, member’s payment responsibility, and balance billing limitations.

Medicare Advantage Private-Fee-For-Service (PFFS) Claim Reimbursement

If you have rendered services for a Blue out-of-area Medicare Advantage PFFS member, but are not obligated to provide services to such member under a contract with a Blue Cross Blue Shield Plan, you will generally be reimbursed the Medicare allowed amount for all covered services (i.e., the amount you would collect if the beneficiary were enrolled in traditional Medicare). Providers should make sure they understand the applicable Medicare Advantage reimbursement rules by reviewing the Terms & Conditions under the member’s Blue Plan. Other than the applicable member cost sharing amounts, reimbursement is made directly by a Blue Cross Blue Shield Plan. In general, you may collect only the applicable cost sharing (e.g., co-payment) amounts from the member at the time of service, and may not otherwise charge or balance bill the member.

NOTE TO PROVIDER: The reimbursement information below applies when a provider treats a Blue Cross Blue Shield Medicare Advantage member to whom the provider’s contract applies. 

Examples:

  • A provider that is contracted for Medicare Advantage PPO business treats an out-of-area Medicare Advantage PPO member.
  • A provider that is contracted for Medicare Advantage HMO business treats an MA HMO member from the local plan.

If you are a provider who accepts Medicare assignment and you render services to any Blue Cross Blue Shield Medicare Advantage member for whom you have an obligation to provide services under your contract with a Blue Cross Blue Shield Plan, you will be considered a contracted provider and be reimbursed per the contractual agreement.

Providers should make sure they understand the applicable Medicare Advantage reimbursement rules and their individual Plan contractual arrangements.

Other than the applicable member cost sharing amounts, reimbursement is made directly by a Blue Cross Blue Shield Plan. In general, you may collect only the applicable cost sharing (e.g., co-payment) amounts from the member at the time of service, and may not otherwise charge or balance bill the member.

Medicare Advantage Coordination of Care Program

A new national Coordination of Care Program to Support Blue MA members was launched on January 1, 2020.  The program aims to increase the quality of members’ care by enabling Blue MA PPO group members to receive appropriate care, wherever they access care.

To better support all Blue MA PPO group members resided in Western New York, Highmark Blue Cross Blue Shield of Western New York is working with providers to improve these members’ care through:

  • Supporting providers with additional information about open gaps in care.
  • Requesting medical records to give Plans a complete understanding of member health status MA PPO group members participating into this program can be identified as having a member address in Western New York and based on the following logo included on their Blue Cross /or Blue Shield ID cards

What does this new program to support Blue Medicare Advantage members mean to me?

This program will result in some changes, including a number that will be beneficial to you, your practice and your patients.  The program serves all MA PPO group members that reside in Highmark Blue Cross Blue Shield of Western New York’s service area, and some of the benefits that you may see include:

  • You will receive consolidated information on gaps in care and risk adjustment gaps, as well as medical record requests for all Blue MA PPO members enrolled with Highmark Blue Cross Blue Shield of Western New York and other Blue Plans and residing in Western New York through local communication practices.
  • The MA PPO group members that you see may come into your practice setting more frequently for care due to Highmark Blue Cross Blue Shield of Western New York’s requesting care gap closures, allowing for greater continuity in care.

Reminder:  As outlined in your contract with Highmark Blue Cross Blue Shield of Western New York, you are to respond to requests in support of risk adjustment, HEDIS and other government required activities within the requested time frame.  This includes request from Highmark Blue Cross Blue Shield of Western New York related to this program.   


What are some changes that I should expect as a result of this program?

Medical Record Requests

Providers will receive medical record requests from Highmark Blue Cross Blue Shield of Western New York related to your patients that are MA PPO group members residing in Western New York and enrolled with another Blue Plan.  Per the program structure, these members’ Plans request medical records through Highmark Blue Cross Blue Shield of Western New York.  You do not need to be in contact with any Blue Plan that you are not contracted with for the purposes of medical record retrieval.

Gap Closure Requests

You may receive an increase in Stars and Risk Adjustment gap closure requests from Highmark Blue Cross Blue Shield of Western New York for your patients that are MA PPO group members residing in Western New York and enrolled with another Blue Plan.  Per the program structure, Stars or risk adjustment gaps for these members are communicated through the local process administered by Highmark Blue Cross Blue Shield of Western New York.  You do not need to be in contact with ay Blue Plan that you are not contracted with for the purposes of gap closure.  In addition, this program change may result in greater contact with these members-whether it is through onsite visits or via phone outreach, and may engender better care continuity.

MA Incentive Program(s)

There may be an increase in the number of patients that are a part of your provider incentive program due to the inclusion of all Blue MA PPO group members residing in Western New York. This may result in greater opportunities for your practice to meet the threshold of the incentive program and increase your incentive payment.

If you have any questions about this program, please contact your provider representative.

HIPAA/Privacy

Consistent with HIPPA and any other applicable law and regulations Highmark Blue Cross Blue Shield of Western New York is contractually bound to preserve the confidentiality of health plan members’ protected health information (PHI) obtained from medical records and provider engagement on Stars and/or risk adjustment gaps. You will only receive requests from Highmark Blue Cross Blue Shield of Western New York that are permissible under applicable law and, consistent with your current practices, patient –authorized information releases are not required in  order for your to fulfill medical records requests and support closure of Stars and/or risk adjustment gaps received pursuant to this care coordination program.

If you have any questions regarding the applicability of HIPAA or any other privacy law or regulation to this program, please contact your provider representative.

If you have any questions in regards to the following Topics please contact your provider representative:

Member Care & Administrative Reminders

Annual Wellness Visits

Documentation Required for Care Gap Closure

Member Experience

Performance Metrics and Tools Vendor Outreach Supporting Provider Engagement

Medicare Risk Adjustment

Importance of Coding Accuracy

Health Insurance Marketplaces (AKA Exchanges)


Health Insurance Marketplace Overview

The Patient Protection and Affordable Care Act  (ACA) of 2010 provides for the establishment of Health Insurance Marketplaces (i.e. Exchanges), in each state, where individuals and small businesses can purchase qualified insurance coverage.

The intent of the Marketplace is to:

  • Create a competitive health insurance marketplace by offering consumers a choice of health insurance plans,
  • Establish common rules regarding insurance offerings and pricing,
  • Provide information to help consumers better understand the options available to them and,
  • Allow individuals and small businesses to have the purchasing power comparable to that of large businesses

The Marketplaces makes it easier for consumers to compare health insurance plans by providing transparent information about health insurance plan provisions such as product information, premium costs, and covered benefits, as well as a plan’s performance in encouraging wellness, managing chronic illnesses, and improving consumer satisfaction.

All states have health insurance marketplaces where consumers can compare health insurance product features, coverage, and costs. Some states have set up their own, state-based Marketplace. In other states, the U.S. Department of Health and Human Services (HHS) has established a federally facilitated Marketplace, federally supported Marketplace, or a state-partnership Marketplace in the state. Blue plans that offer products on the Marketplaces collaborate with the state and federal governments for eligibility, enrollment, reconciliation, and other operations to ensure that consumers can seamlessly enroll in individual and small business health insurance products.

Exchange Individual Grace Period

The ACA mandates a three month grace period for individual members who receive a premium subsidy from the government and are delinquent in paying their portion of premiums. The grace period applies as long as the individual has previously paid at least one month’s premium within the benefit year. The health insurance plan is only obligated to pay claims for services rendered during the first month of the grace period. The ACA clarifies that the health insurance plan may pend claims during the second and third months of the grace period.

Blue Plans are required to either pay or pend claims for services rendered during the second and third month of the grace period. Consequently, if a member is within the last two months of the federally mandated individual grace period, providers may receive a notification from Highmark Blue Cross Blue Shield of Western New York indicating that the member is in the grace period.

Exchange Individual Grace Period – Post Service Notification Letter to Provider

Communication to providers will include the following information:

 1. Notice-unique identification number (claim includes member information):

Claim #: __________

2. Name of the QHP and affiliated issuer (Home Plan name)

3. Explanation of the three month grace period:

Under the Patient Protection and Affordable Care Act (PPACA), there is a three month grace period under Exchange-purchased individual insurance policies, when a premium due is not received for members eligible for premium subsidies. During this grace period, carriers may not dis-enroll members and, during the second and third months of the grace period, are required to notify providers about the possibility that claims may be denied in the event that the premium is not paid.

4. Purpose of the notice, applicable dates of whether the enrollee is in the second or third month of the grace period & individuals affected under the policy and possibly under care of the provider:

Please be advised that a premium due has not been received for this subsidy eligible member and that the member and any eligible dependents are and at the time that your care was provided, were in the second or third month of the Exchange individual health insurance grace period. The above-referenced claim thus was pended due to non-payment of premium, and will be denied if the premium is not paid by the end of the grace period.

5. Consequences:

If the premium is paid in full by the end of the grace period, any pended claims will be processed in accordance with the terms of the contract. If the premium is not paid in full by the end of the grace period, any claims incurred in the second and third months may be denied.

6. QHP customer service telephone number:

Please feel free to contact Highmark Blue Cross Blue Shield of Western New York Monday through Friday, at 1-800-444-2012 if you have any questions regarding this claim.

Health Insurance Marketplaces Claims
 

What else do I need to know?

 

The products offered on the Marketplaces will follow local business practices for processing and servicing claims. Providers should continue to follow current practices with Highmark Blue Cross Blue Shield of Western New York for claims processing and handling such as outlined below. 

 

  • Eligibility and Benefits
  • Care Management
    • Pre-Service Review
    • Medical Policy
  • Claim Pricing and Processing
    • Contracting
    • Claim Filing
    • Pricing
    • Claim Processing
    • Medical Records
    • Payment
    • Customer Service

Who do I contact if I have a question about Health Insurance Marketplaces (Exchanges)?

 

If you have any questions regarding the Health Insurance Marketplaces, please contact Highmark Blue Cross Blue Shield of Western New York at 1-800-666-4627

 

Medicaid Claims

 

Blue Plans currently administer Medicaid programs in various states across the U.S. as Managed Care Organizations (MCO), providing comprehensive Medicaid benefits to the eligible population.  Because Medicaid is a state-run program, requirements vary for each state, and thus each BCBS Plan.  Medicaid members have limited out-of-state benefits, generally covering only emergent situations.  In some cases, such as continuity of care, children attending college out-of-state, or a lack of specialists in the member’s home state, a Medicaid member may receive care in another state, and generally the care requires prior authorization.

 

Identifying Medicaid Members to Determine Eligibility and Benefits

 

BCBS ID cards do not always indicate that a member has a Medicaid product. ID cards for Medicaid members do not include the suitcase logo that you may have seen on most ID cards, but they do include a disclaimer on the back providing information on benefit limitations. For members with such ID cards, you should obtain eligibility and benefit information and prior authorization for services using the same tools as you would for other BCBS members.

 

  • Submit an eligibility inquiry by call the BlueCard Eligibility Line at 1-800-676-BLUE (2583)
  • Submit an eligibility inquiry using Blue Exchange
  • Obtain preservice review using the Electronic Provider Access (EPA) tool

Medicaid Reimbursement and Billing

 

Claims for all BCBS Medicaid members should be submitted to your local BCBS Plan. If you are contracted with your local BCBS Plan for Medicaid, your local Medicaid rates will only apply for Highmark Blue Cross Blue Shield of Western New York members; they do not apply to out-of-state Medicaid members.  When you see a Medicaid member from another state and submit the claim, you must accept the Medicaid fee schedule that applies in the member’s home state.


Please remember that billing out-of-state Medicaid members for the amount between the Medicaid-allowed amount and charges for Medicaid-covered services is prohibited by Federal regulations (42 CFR 447.15).


If you provide services that are not covered by Medicaid to a Medicaid member, you will not be reimbursed. You may only bill a Medicaid member for services not covered by Medicaid if you have obtained written approval from the member in advance of the services being rendered.


In some circumstances, a state Medicaid program will have an applicable copayment, deductible or coinsurance applied to the member’s plan. You may collect this amount from the member as applicable. Note that the coinsurance amount is based on the Medicaid fee schedule for that service.

Medicaid Billing Data Requirements

When billing for a Medicaid member, please remember to check the Medicaid website of the state where the member resides for information on Medicaid billing requirements. 

Providers should always include their National Provider Identifier (NPI) on Medicaid claims, unless the provider is considered atypical. Providers should also bill using National Drug Codes (NDC) on applicable claims.  These data elements and other data elements that are important to submit, when applicable, on Medicaid claims are included below.

Applicable Medicaid claims submitted without these data elements will be denied: 

  • National Drug Code
  • Rendering Provider Identifier (NPI)
  • Billing Provider Identifier (NPI)

Applicable Medicaid claims submitted without these data elements may be pended or denied until the required information is received:

  • Billing Provider (Second) Address Line
  • Billing Provider Middle Name or Initial
  • (Billing) Provider Taxonomy Code
  • (Rendering) Provider Taxonomy Code
  • (Service) Laboratory or Facility Postal Zone or Zip Code
  • (Ambulance) Transport Distance
  • (Service) Laboratory Facility Name
  • (Service) Laboratory or Facility State or Province Code
  • Value Code Amount
  • Value Code
  • Condition Code
  • Occurrence Codes and Dates
  • Occurrence Span Codes and Dates
  • Referring Provider Identifier and Identification Code Qualifier
  • Ordering Provider Identifier and Identification Code Qualifier
  • Attending Provider NPI
  • Operating Physician NPI
  • Claim or Line Note Text
  • Certification Condition Applies Indicator and Condition Indicator (Early and Periodic screening diagnosis and treatment (EPSDT)
  •  Service Facility Name and Location Information
  • Patient Weight
  • Ambulance Transport Reason Code
  • Round Trip Purposed Description
  • Stretcher Purpose Description

Medicaid Encounter Data Reporting

The data elements mentioned above need to be included on Medicaid claims, so that BCBS MCOs are able to comply with encounter data reporting requirements applicable in their respective state.

Provider Enrollment Requirements

 

Some states require that out-of-state providers enroll in their state’s Medicaid program in order to be reimbursed. Some of these states may accept a provider’s Medicaid enrollment in the state where they practice to fulfill this requirement.

 

If you are required to enroll in another state’s Medicaid program, you should receive notification upon submitting an eligibility or benefit inquiry. You should enroll in that state’s Medicaid program before submitting the claim. To view provider enrollment requirements for BCBS Medicaid states, refer to the applicable states website for guidance.

 

If you submit a claim without enrolling, your Medicaid claims will be denied an you will receive the following message from Highmark Blue Cross Blue Shield of Western New York regarding the Medicaid provider enrollment requirements, “The state where the member is enrolled in Medicaid requires that providers enroll in their Medicaid program before the Plan can pay the provider.  To view provider enrollment requirements for the state where the member is enrolled, please visit https://www.emedny.org/info/ProviderEnrollment/index.aspx.

 

You will be required to enroll before the Medicaid claim can be processed and before you receive reimbursement.

Medicaid Questions

How do I submit Medicaid claims?

Medicaid claims should be submitted to your local BCBS Plan in the same manner as you submit claims for other BCBS members. You will also receive your payment in the same manner, although the payment amount will likely be different from your contracted rate, or different from the Medicaid rate in the state in which you practice

How do I know I am seeing a Medicaid member?

Members enrolled in a BCBS Medicaid product are issued BCBS ID cards. Medicaid ID cards do not always indicate that a member is enrolled in a Medicaid product. Medicaid ID cards:

  • Will not include a suitcase logo
  • Will contain disclaimer language on the back of the ID card indicating benefit limitations for provider awareness, for example, “This member has limited benefits outside of Highmark Blue Cross Blue Shield of Western New York.  Providers should request eligibility / benefit information.

Providers should always submit an eligibility inquiry if the ID card has no suitcase logo and includes a disclaimer with benefit limitations, using the same tools available for BlueCard.

  • BlueCard Eligibility Line
  • BlueExchange

What amount should I expect to receive for members that reside outside of Highmark Blue Cross Blue Shield of Western New York’s service area?

When billing for services rendered to an out-of-state Medicaid member, you will be reimbursed according to the member’s home state Medicaid fee schedule, which may or may not be equal to what you are accustomed to receiving for the same service in your state.

My state does not require me to include an NPI or NDC code and many of the other data elements listed above on a Medicaid claim. Why do I have to include these codes?

Members should include these data elements on applicable BCBS Medicaid claims or the claims may be pended or denied.

Whom do I contact if I have questions?

For general questions, regarding Highmark BCBSWNY-Medicaid &CHP the provider can call 1-866-231-0847. If it is regarding general questions for enrollment in NY Medicaid, they should contact emedny at 1-800-343-9000.

Claims Coding

Code claims as you would for Highmark Blue Cross Blue Shield of Western New York

Ancillary Claims

Ancillary providers include Independent Clinical Laboratory, Durable/Home Medical Equipment and Supplies and Specialty Pharmacy providers. File claims for these providers as follows:

  • Independent Clinical Laboratory (Lab) – File to the BCBS plan in whose service area the referring provider is located.
  • Durable/Home Medical Equipment and Supplies (D/HME) – File to the Plan in whose service area the equipment was shipped to or purchased at a retail store.
  • Specialty Pharmacy – File to the Plan in whose service area the ordering physician is located.

Refer to Ancillary Claims filing Mandate on Provider Portal, BlueCard Section

Air Ambulance Claims

Claims for air ambulance services must be filed to the Blue Plan in whose service area the point of pickup ZIP code is located.

Note: If you contract with more than one Plan in a state for the same product type (i.e., PPO or Traditional), you may file the claim with either Plan.

Service Rendered How to file
(required fields)
Where to file Example
Air Ambulance Services Point of pickup ZIP Code:
  • Populate item 23 on CMS 1500 Health Insurance Claim Form, with the 5-digit ZIP code of the point of pickup
    • For electronic billers, populate the origin information (ZIP code of the point of pick-up), in the Ambulance Pick-Up Location Loop in the ASC X12N Health Care Claim (837) Professional.
  • Where Form CMS-1450 (UB-04) is used for air ambulance service not included with local hospital charges, populate Form Locators 39-41, with the 5-digit ZIP code of the point of pickup. The Form Locator must be populated with the approved Code and Value specified by the National Uniform Billing Committee in the UB-04 Data Specifications Manual. 
    • Form Locators (FL) 39-41
    • Code: A0 (Special ZIP code reporting), or its successor code specified by the National Uniform Billing Committee.
    • Value: Five digit ZIP Code of the location from which the beneficiary is initially placed on board the ambulance.
    • For electronic claims, populate the origin information (ZIP code of the point of pick-up) in the Value Information Segment in the ASC X12N Health Care Claim (837) Institutional.

File the claim to the Plan in whose service area the point of pickup ZIP code is located*.

 

*BlueCard rules for claims incurred in an overlapping service area and contiguous county apply. 

 

  • The point of pick up ZIP code is in Plan A service area.
  • The claim must be filed to Plan A, based on the point of pickup code

 

 

  • The air ambulance claims filing rules apply regardless of the provider’s contracting status with the BCBS Plan where the claim is filed.
  • Where possible, providers are encouraged to verify Member Eligibility and Benefits by contacting the phone number on the back of the Member ID card or calling 1-800-676-BLUE(2583).
  • Providers are encouraged to utilize in-network participating air ambulance providers to reduce the risk of additional member’s liability for covered benefits.  A list of in-network participating providers may be obtained by contacting Highmark Blue Cross Blue Shield of Western New York.
  • Members are financially liable for air ambulance services not covered under their benefit plan.  It is the provider’s responsibility to request payment directly from the member for non-covered services.
  • Providers who wish to establish Trading Partner Agreements with other Plans should reference Highmark Blue Cross Blue Shield of Western New York's website to obtain additional contact information.
  • If you have any questions about where to file your claim, please contact Highmark Blue Cross Blue Shield of Western New York BlueCard Service Line at 1-800-444-2012.

Contiguous Counties/Overlapping Service Area

Contiguous Counties

Claims may be filed directly to the member’s BCBS Plan by contiguous area providers based on the permitted terms of the provider contact, which may include:

  • Provider Location (i.e., Plan service area is the provider's office located)
  • Provider contract with the two contiguous counties (i.e., is the provider contracted with only one or both service areas).
  • The member’s BCBS plan (i.e. is the member’s BCBS Plan in a county contiguous to the provider location).
  • The member’s location (i.e. does the member live or work in the service area covered by his/her BCBS Plan).
  • The location of where the services were received (i.e. did the member receive service from a provider located in a county contiguous to the member’s BCBS Plan).

Overlapping Service Areas

Submission of claims in Overlapping Service Areas is dependent on what Plan(s) the Provider contracts with in that service area, the type of contract the Provider has (ex. PPO, Traditional) and the type of contract the member has with their BCBS Plan.

  •  If you contract with all local BCBS Plans in your state for the same product type (i.e., PPO or Traditional), you may file an out-of-area member’s claim with either Plan.
  • If you have a PPO contract with one BCBS Plan, but a Traditional contract with another BCBS Plan, file the out-of-area member’s claim by product type.
  • For example, if it’s a PPO member, file the claim with the Plan that has your PPO contract.
  • If you contract with one BCBS Plan, but not the other, file all out-of-area claims with your contracted Plan.

Medical Records

BCBS Plans have made many improvements to the medical records process to make it more efficient and are able to send and receive medical records electronically with other BCBS Plans. This method significantly reduces the time it takes to transmit supporting documentation for our out of area claims, reduces the need to request records multiple times and significantly reduces lost or misrouted records.

Under what circumstances may the provider get requests for medical records for out-of-area members?
 

  1. As part of the preauthorization process — If you receive requests for medical records from other BCBS Plans prior to rendering services, as part of the pre-authorization process, you will be instructed to submit the records directly to the member’s Plan that requested them.  This is the only circumstance where you would not submit them to Highmark Blue Cross Blue Shield of Western New York.
  2. As part of claim review and adjudication — These requests will come from Highmark Blue Cross Blue Shield of Western New York in the form of a letter, fax, email, or electronic communication 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, should be received by your office requesting the needed information.
  2. A remittance may be received by your office indicating the claim is being denied pending receipt and review of records. Occasionally, the medical records you submit might cross in the mail with the remittance advice for the claim indicating a need for medical records. A remittance advice is not a duplicate request for medical records. If you submitted medical records previously, but received a remittance advice indicating records were still needed, please contact Highmark Blue Cross Blue Shield of Western New York BlueCard Service 1-800-444-2012 to ensure your original submission has been received and processed. This will prevent duplicate records being sent unnecessarily.
  3. If you received only a remittance advice indicating records are needed, but you did not receive a medical records request letter, contact Highmark Blue Cross Blue Shield of Western New York to determine if the records are needed from your office.
  4. Upon receipt of the information, the claim will be reviewed to determine the benefits.
     

  

Helpful Ways You Can Assist in Timely Processing of Medical Records

  1. If the records are requested following submission of the claim, forward all requested medical records to Highmark Blue Cross Blue Shield of Western New York.
  2. Follow the submission instructions given on the request, using the specified physical or email address or fax number. The address or fax number for medical records may be different than the address you use to submit claims.
  3. Include the cover letter you received with the request when submitting the medical records. This is necessary to make sure the records are routed properly once received by Blue Cross Blue Shield of Western New York.
  4. Please submit the information to Highmark Blue Cross Blue Shield of Western New York as soon as possible to avoid further delay.
  5. Only send the information specifically requested. Frequently, complete medical records are not necessary.
  6. Please do not proactively send medical records with the claim. Unsolicited claim attachments may cause claim payment delays.

Please mail to:

BlueCard Dept.
Highmark Blue Cross Blue Shield of Western New York
PO Box 80
Buffalo, NY 14240


Adjustments

Contact Highmark Blue Cross Blue Shield of Western New York if an adjustment is required. We will work with the member’s BCBS Plan for adjustments; however, your workflow should not be different.


Appeals

You must submit a provider claims appeal form located on the Provider web website.

Appeals for all claims are handled through Highmark Blue Cross Blue Shield of Western New York. We will coordinate the appeal process with the member’s Blue Plan, if needed.


Coordination of Benefits (COB) Claims

Coordination of benefits (COB) refers to how we ensure members receive full benefits and prevent double payment for services when a member has coverage from two or more sources. The member's contract language explains the order for which entity has primary responsibility for payment and which entity has secondary responsibility for payment.

  •  Highmark Blue Cross Blue Shield of Western New York or any other BCBS Plan is the primary payer, submit other carrier’s name and address with the claim to Highmark Blue Cross Blue Shield of Western New York. If you do not include the COB information with the claim, the member’s BCBC Plan will have to investigate the claim. This investigation could delay your payment or result in a post-payment adjustment, which will increase your administrative burden
  • Other non-BCBS health plan is primary and Highmark BCBSWNY  or any other BCBS Plan is secondary, submit the claim to Highmark Blue Cross Blue Shield of Western New York only after receiving payment from the primary payer, including the explanation of payment from the primary carrier. If you do not include the COB information with the claim, the member’s BCBS Plan will have to investigate the claim. This investigation could delay your payment or result in a post-payment adjustment, which will increase your administrative burden.

Carefully review the payment information from all payers involved on the remittance advice before balance billing the patient for any potential liability. The information listed on the Highmark Blue Cross Blue Shield of Western New York remittance advice as “patient liability” might be different from the actual amount the patient owes you, due to the combination of the primary insurer payment and your negotiated amount with Highmark Blue Cross Blue Shield of Western New York.

For Professional claims if the member does not have other insurance, it is imperative on the electronic HIPAA 837 claims submission transaction or CMS 1500 claim form, in box 11D, either “YES” or “NO” be checked. Leaving the box unmarked can cause the member’s Plan to stop the claim to investigate for COB.

Coordination of Benefits Questionnaire

To streamline our claims processing and reduce the number of denials related to Coordination of Benefits, a Coordination of Benefits (COB) questionnaire is available to you on our website and will help you and your patients avoid potential claim issues.

When you see any Blue members and you are aware that they might have other health insurance coverage give a copy of the questionnaire to them during their visit. Providers should ensure that the form is completely filled out and at a minimum, includes your name and tax identification or NPI number, the policy holder’s name, group number and identification number including the three character prefix and the member’s signature. Once the form is complete, send it to your local BCBS Plan as soon as possible. Your local BCBS Plan will work with the member’s Plan to get the COB information updated. Collecting COB information from members before you file their claim eliminates the need to gather this information later, thereby reducing processing and payment delays.

Claim Payment

  • If you have not received payment for a claim, do not resubmit the claim because it will be denied as a duplicate. This also causes member confusion because of multiple Explanations of Benefits (EOBs).  Highmark Blue Cross Blue Shield of Western New York’s standard time for claims processing is 30 days, however claim processing times at various BCBS  Plans vary. 
  • If you do not receive your payment or a response regarding your payment, please call Highmark Blue Cross Blue Shield of Western New York at 1-800-444-2012  or visit our online transaction site to check the status of your claim at HEALTHeNET.
  • In some cases, a member’s BCBS Plan may pend a claim because medical review or additional information is necessary. When resolution of a pended claim requires additional information from you, Highmark Blue Cross Blue Shield of Western New York may either ask you for the information or give the member’s Plan permission to contact you directly.

Claim Status Inquiry

Highmark Blue Cross Blue Shield of Western New York is your single point of contact for all claim inquiries.  Claim status inquires can be done by:

Phone: 1-800-444-2012
Electronically: Log on to HEALTHeNET

Calls from Members and Others with Claim Questions

If BCBS Plan members contact you, advise them to contact their BCBS Plan and refer them to their ID card for a customer service phone number.

The member’s BCBS Plan should not contact you directly regarding claims issues, the member’s BCBS Plan contacts you directly and asks you to submit the claim to them, refer them to Highmark Blue Cross Blue Shield of Western New York.

Value-Based Provider Arrangements

Plans have value-based care delivery arrangements in place with their providers. Each Plan has created their own arrangement with their provider(s), including reimbursement arrangements. Due to the unique nature of each plan/provider arrangement, there is no common provider education template for value-based care delivery arrangements that can be created and distributed for use by all plans.

Key Contacts

For more information:

  • Visit the Highmark Blue Cross Blue Shield of Western New York Website
  • Call Highmark Blue Cross Blue Shield of Western New York at 1-800-444-2012
  • Contact your Highmark Blue Cross Blue Shield of Western New York provider service representative

Section 4 - Frequently Asked Questions

BlueCard Basics
 

1. What Is the BlueCard® Program?

BlueCard is a national program that enables members of one BCBS Plan to obtain health care services while traveling or living in another Blue Cross and Blue Shield Plan’s service area. The program links participating health care providers with the independent Blue Cross and Blue Shield Plans across the country and in more than 200 countries and territories worldwide through a single electronic network for claims processing and reimbursement.

The program allows you to conveniently submit claims for patients from other BCBS Plans, domestic and international, to your local BCBS Plan. Your local BCBS Plan is your sole contact for claims payment, adjustments and issue resolution.

2. What Products are included in the BlueCard Program?

  • Traditional (indemnity insurance)
  • PPO (Preferred Provider Organization)
  • EPO (Exclusive Provider Organization), including Blue High Performance Network (Blue HPN)
  • POS (Point of Service)
  • HMO (Health Maintenance Organization)
  • Medicare Advantage

3. What products and accounts are excluded from the BlueCard Program?

Stand-alone dental and prescription drugs are excluded from the BlueCard Program. In addition, claims for the Federal Employee Program (FEP) are exempt from the BlueCard Program. Please follow your FEP billing guidelines.

4. What is the BlueCard Managed Care/POS Model?

The BlueCard Managed Care/POS program is for members who reside outside their BCBS Plan’s service area. Under the BlueCard Managed Care/POS model, members are enrolled in Highmark Blue Cross Blue Shield of Western New York’s network and have a primary care physician (PCP). You can recognize BlueCard Managed Care/POS members who are enrolled in the Highmark Blue Cross Blue Shield of Western New York network through the member ID card as you do for all other BlueCard members.

5. Are HMO patients serviced through the BlueCard® Program?

Occasionally, BCBS HMO members affiliated with other BCBS Plans will seek care at your office or facility. You should handle claims for these members the same way you do for Highmark Blue Cross Blue Shield of Western New York members by submitting them to Highmark Blue Cross Blue Shield of Western New York.

Identifying Members and ID Cards
 

1. How do I identify members?

When members from other BCBS Plans arrive at your office or facility, be sure to ask them for their current identification card. The main identifier for out of area members is the prefix. The ID cards may also have:

  • PPO in a suitcase logo, for eligible PPO members
  • Blank suitcase logo
  • An HPN in a suitcase logo with the Blue High Performance Network (HPN) name in the upper right or lower corner, for Blue HPN EPO members

2. What is a "prefix?"

The three-character prefix at the beginning of the member's identification number is the key element used to identify and correctly route claims. The prefix identifies the BCBS Plan or national account to which the member belongs. It is critical for confirming a patient's membership and coverage.

3. What do I do if a member has an identification card without a prefix?

Some members may carry outdated identification cards that may not have a prefix.  Please request a current card from the member.

4. How do I identify BlueCard Managed Care/POS member

The BlueCard Managed Care model is for members who reside outside their BCBS Plan's service area. BlueCard Managed Care/POS members are enrolled in Highmark Blue Cross Blue Shield of Western New York’s network and primary care physician (PCP) panels. You can recognize BlueCard Managed Care/POS members who are enrolled in Highmark Blue Cross Blue Shield of Western New York network through the member ID card as you do for all other BlueCard members.

5. How do I identify Medicare Advantage members?

Members will not have a standard Medicare card; instead, a BCBS logo will be visible on the ID card. The following examples illustrate how the different products associated with the Medicare Advantage program will be designated on the front of the member ID cards:

Medicare member ID card acronyms

When these logos are displayed on the front of a member’s ID card, it indicates the coverage type the member has in his/her BCBS Plan service area or region. However, when the member receives services outside his/her BCBS Plan service area or region, provider reimbursement for covered services is based on the Medicare allowed amount, except for PPO network-sharing arrangements.

Highmark Blue Cross Blue Shield of Western New York participates in Medicare Advantage PPO Network Sharing arrangements, and contracted provider reimbursement is based on the contracted rate with Highmark Blue Cross Blue Shield of Western New York. Non-contracted provider reimbursement is the Medicare allowed amount based on where services are rendered.

Tip:  While all MA PPO members have suitcases on their ID cards, some have limited benefits outside of their primary carrier’s service area. Providers should refer to the back of the member’s ID card for language indicating that such restrictions apply.

6. How do I identify international members?

Occasionally, you may see identification cards from members residing abroad or foreign BCBS Plan members. These ID cards will also contain three-character prefixes. Please treat these members the same as domestic Blue Plan members.

7. What do I do if a member doesn't have an ID card?

The member would need to be asked whom their plan coverage is with along with the three-character prefix and their identification number. Once you have the member information, you would call 1-800-810-BLUE to obtain eligibility and benefits for the member.

Verifying Eligibility and Coverage
 

1. How do I verify membership and coverage?

For Highmark Blue Cross Blue Shield of Western New York members, contact our Customer Services Department at 1-800-544-2583. Providers can also log on to HEALTHeNET to verify member eligibility.

For other Blue Plans members, contact BlueCard Eligibility® by phone or Highmark Blue Cross Blue Shield of Western New York electronically at HEALTHeNET to verify the patient’s eligibility and coverage:

Phone: 1-800-676-BLUE (2583)

Utilization Review

1. How do I obtain utilization review?

You should remind patients that they are responsible for obtaining precertification/authorization for outpatient services from their BCBS plan. Participating providers are responsible for obtaining pre-service review for inpatient facility services when the services are required by the account or member contract (Provider Financial Responsibility).

You may also contact the member's Plan on the member's behalf. You can do so by:

For Highmark Blue Cross Blue Shield of Western New York members, contact our Utilization Management department at 1-800-677-3086 or (716) 884-2942.

For other Blue plans members:

  • Phone - Call the utilization management/precertification number on the back of the member’s card. If the utilization management number is not listed on the back of the member’ card – call 1-800-676-BLUE (2583) and ask to be transferred to the utilization review area
  • Electronic: Submit a HIPAA 278 transaction (referral/authorization) to HEALTHeNET.

 

Claims

1. Where and how do I submit claims?

You should always submit claims electronically to Highmark Blue Cross Blue Shield of Western New York. Be sure to include the member's complete identification number when you submit the claim. The complete identification number includes the three character prefix —do not make up prefixes. Claims with incorrect or missing prefixes and member identification numbers cannot be processed.

2. How do I submit international claims?

The claim submission process for international BCBS Plan members is the same as for domestic BCBS Plan members. You should submit the claim directly to Highmark Blue Cross Blue Shield of Western New York.

3. How do I handle COB claims?

If after calling 1-800-676-BLUE or through other means you discover the member has a COB provision in their benefit plan and Highmark Blue Cross Blue Shield of Western New York is the primary payer, submit the claim with information regarding COB to:

Highmark Blue Cross Blue Shield of Western New York
PO Box 80
Buffalo, New York 14240-0080

If you do not include the COB information with the claim, the member's BCBS Plan or the insurance carrier will have to investigate the claim. This investigation could delay your payment or result in a post-payment adjustment, which will increase your volume of bookkeeping.

4. How do I handle Medicare Advantage Claims?

Submit claims to Highmark Blue Cross Blue Shield of Western New York. Do not bill Medicare directly for any services rendered to a Medicare Advantage member. Payment will be made directly by Highmark Blue Cross Blue Shield of Western New York.

5. How do I handle traditional Medicare-related claims?

 

  • When Medicare is the primary payer, submit claims to your local Medicare intermediary.
  • All BCBS claims are set up to automatically cross over (or forward) to the member’s BCBS Plan after being adjudicated by the Medicare intermediary.

6. How do I submit Medicare Primary/Blue Plan Secondary claims?

 

  • For members with Medicare primary coverage and BCBS Plan secondary coverage, submit claims to your Medicare intermediary and/or Medicare carrier.
  • When submitting the claim, it is essential that you enter the correct BCBS Plan name as the secondary carrier. This may be different from the local BCBS Plan. Check the member’s ID card for additional verification.
  • Be certain to include the prefix as part of the member identification number. The member’s ID will include the prefix in the first three positions. The prefix is critical for confirming membership and coverage, and key to facilitation prompt payments.

When you receive the remittance advice from the Medicare intermediary, look to see if the claim has been automatically forwarded (crossed over) to the Blue Plan.

  • If the remittance advice indicates that the claim was crossed over, Medicare has forwarded the claim on your behalf to the appropriate BCBS Plan and the claim is in the process. DO NOT resubmit that claim to Highmark Blue Cross Blue Shield of Western New York. Duplicate claims will result in processing and payment delays.
  • If the remittance advice indicates that the claim was not crossed over, submit the claim to Highmark Blue Cross Blue Shield of Western New York, with the Medicare remittance advice.
  • In some cases, the member identification card may contain a COBA ID number. If so, be certain to include that number on your claim.
  • For claim status inquiries, contact Highmark Blue Cross Blue Shield of Western New York at 1-800-444-2012.

7. When will I get paid for BlueCard® claims?

Highmark Blue Cross Blue Shield of Western New York's Guidelines for Claims Payment BlueCard payments go out the same as any other payment to the provider. They will receive their remittance with the BlueCard claim number and the member prefix and ID number.

If you haven't received payment, do not resubmit the claim. If you do, Highmark Blue Cross Blue Shield of Western New York will have to deny the claim as a duplicate. You will also confuse the member because he or she will receive another EOB and will need to call customer service. Please understand that timing for claims processing varies at each Blue Cross Blue Shield Plan.

The next time you don't receive your payment or a response regarding your payment, please call Highmark Blue Cross Blue Shield of Western New York at 1-800-444-2012.  In some cases, a member's Blue Cross and Blue Shield Plan may suspend a claim because medical review or additional information is necessary. When resolution of claim suspensions requires additional information from you, Highmark Blue Cross Blue Shield of Western New York will ask you for the information.

Contacts
 

1. Who do I contact with claims questions?

Highmark Blue Cross Blue Shield of Western New York
1-800-444-2012

2. How do I handle calls from members and others with claims questions?

If members contact you, tell them to contact their BCBS Plan. Refer them to the front or back of their ID card for a customer service number. A member's BCBS Plan should not contact you directly, unless you filed a paper claim directly with that Plan. If the member's Plan contacts you to send them another copy of the member's claim, refer the Plan to Highmark Blue Cross Blue Shield of Western New York.

3. Where can I find more information?

 

  • Visit Blue Cross Blue Shield website https://www.bcbswny.com
  • Call Highmark Blue Cross Blue Shield of Western New York at 1-800-444-2012
  • Contact your Highmark Blue Cross Blue Shield of Western New York Provider Service Representative

Section 5 - Glossary of BlueCard Program Terms


Administrative Services Only (ASO)

ASO accounts are self-funded, where the local plan administers claims on behalf of the account, but does not fully underwrite the claims. ASO accounts may have benefit or claims processing requirements that may differ from non-ASO accounts. There may be specific requirements that affect; medical benefits, submission of medical records, Coordination of Benefits or timely filing limitations.

Highmark Blue Cross Blue Shield of Western New York receives and prices all local claims, handles all interactions with providers, with the exception of Utilization Management interactions, and makes payment to the local provider.


Affordable Care Act

The comprehensive health care reform law enacted in March 2010. The law was enacted in two parts: The Patient Protection and Affordable Care Act was signed into law on March 23, 2010, and was amended by the Health Care and Education Reconciliation Act on March 30, 2010. The name “Affordable Care Act” is used to refer to the final, amended version of the law.
 

Prefix

Three characters preceding the subscriber identification number on BCBS ID cards that identify the member’s BCBS Plan or National Account.

bcbs.com

The Blue Cross Blue Shield Association’s website.
 

BlueCard Access® 1-800-810-BLUE (2583)

A toll-free 800 number for providers and members to use to locate health care providers in another BCBS Plan’s area. This number is useful when you need to refer the patient to a physician or health care facility in another location.

National Doctor and Hospital Finder Website

A Web site you can use to locate healthcare providers in another BCBS Plan’s area http://www.bcbs.com/healthtravel/finder.html. This is useful when you need to refer the patient to a physician or healthcare facility in another location. If you find that any information about you, as a provider, is incorrect on the Web site, please complete a Provider Demographic Change Form.

Blue High Performance Network(Blue HPN)

A national network of providers offered in key geographies that provides national accounts enhanced quality and cost savings.

BlueCard Eligibility® 1-800-676-BLUE

A toll-free 800 number for you to verify membership and coverage information, and obtain precertification on patients from other BCBS Plans.

Preferred Provider Organization (PPO)

A health benefit program that provides a significant incentive to members when they obtain services from a designated PPO provider. The benefit program does not require a gatekeeper (primary care physician) or referral to access PPO providers

Blue Cross Blue Shield Global Core

A medical assistance program that provides Blue members traveling or living outside the United States, Puerto Rico and U. S. Virgin Islands with access to doctors and hospitals  around the world.

Consumer Directed Healthcare/Health Plans (CDHC/CDHP)

Consumer Directed Healthcare (CDHC) is a broad umbrella term that refers to a movement in the healthcare industry to empower members, reduce employer costs, and change consumer healthcare purchasing behavior. CDHC provides 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.

Coinsurance

A provision in a member’s coverage that limits the amount of coverage by the benefit plan to a certain percentage. The member pays any additional costs out-of-pocket.
 

Coordination of Benefits (COB)

Ensures that members receive full benefits and prevents double payment for services when a member has coverage from two or more sources. The member’s contract language gives the order for which entity has primary responsibility for payment and which entity has secondary responsibility for payment.
 

Copayment

A specified charge that a member incurs for a specified service at the time the service is rendered.
 

Deductible

A flat amount the member incurs before the insurer will make any benefit payments.
 

EPO

A health benefits program in which the member receives no benefits for care obtained outside the PPO network except emergency care and does not include a Primary Care Physician selection. EPO benefit coverage may be delivered via BlueCard PPO and is restricted to services provided by BlueCard PPO providers.

Essential Community Providers

Healthcare providers that serve predominately low-income, high-risk, special needs and medically-underserved individuals. The Department of Health and Human Services (HHS) proposes to define essential community providers as including only those groups suggested in the ACA, namely those named in section 340B(a)(4) of the Public Health Service Act and in section 197(c)(1)(D)(i)(IV) of the Social Security Act.
 

FEP

The Federal Employee Program.
 

Hold Harmless

An agreement with a health care provider not to bill the member for any difference between billed charges for covered services (excluding coinsurance) and the amount the health care provider has contractually agreed on with a BCBS Plan as full payment for these services.
 

Medicare Crossover

The Crossover program was established to allow Medicare to transfer Medicare Summary Notice (MSN) information directly to a payer with Medicare’s supplemental insurance company.
 

Marketplace/Exchange

For purposes of this document, the term Marketplace/Exchange refers to the public exchange as established pursuant to the Affordable Care Act (ACA): A transparent and competitive insurance marketplace where individuals and small businesses can buy affordable and qualified health benefit plans. Affordable Insurance Marketplaces will offer a choice of health plans that meet certain benefits and cost standards. The ACA allows the opportunity for each state to establish a State-based Marketplace. Recognizing that not all states may elect to establish a State-based Marketplace, the ACA directs the Secretary of HHS to establish and operate a Federally-facilitated Marketplace in any state that does not do so, or will not have an operable Marketplace for the 2014 coverage year, as determined in 2013.
 

Medicaid

A program designed to assist low-income families in providing healthcare for themselves and their children. It also covers certain individuals who fall below the federal poverty level. Other people who are eligible for Medicaid include low-income children under age 6 and low-income pregnant women, Medicaid is governed by overall Federal guidelines in terms of eligibility, procedures, payment level, etc., but states have a broad range of options within those guidelines to customize the program to their needs and/or can apply for specific waivers. State Medicaid programs must be approved by CMS; their daily operations are overseen by the State Department of Health (or similar state agency).
 

Medicare Advantage

The program alternative to standard Medicare Part A and Part B fee-for-service coverage; generally referred to as “traditional Medicare.”

MA offers Medicare beneficiaries several product options (similar to those available in the commercial market), including health maintenance organization (HMO), preferred provider organization (PPO), point-of-service (POS) and private fee-for-service (PFFS) plans.

Medicare Supplemental (Medigap)

Pays for expenses not covered by Medicare. Medigap is a term for a health insurance policy sold by private insurance companies to fill the “gaps” in original Medicare Plan coverage. Medigap policies help pay some of the healthcare costs that the original Medicare Plan doesn’t cover.   Medigap policies are regulated under federal and state laws and are “standardized.” There may be up to 12 different standardized Medigap policies (Medigap Plans A through L). Each plan, A through L, has a different set of basic and extra benefits. The benefits in any Medigap Plan A through L are the same for any insurance company. Each insurance company decides which Medigap policies it wants to sell. Most of the Medigap claims are submitted electronically directly from the Medicare intermediary to the member’s BCBS Plan via Medicare Crossover process. Medigap does not include Medicare Advantage products, which are a separate program under the Centers for Medicare & Medicaid Services (CMS). Members who have a Medicare Advantage Plan do not typically have a Medigap policy because under Medicare Advantage these policies do not pay any deductibles, copayments or other cost-sharing.

National Account

An employer group with employee and/or retiree locations in more than one BCBS Plan’s Service Area.
 

Other Party Liability (OPL)

Cost containment programs that ensure that BCBS Plans meet their responsibilities efficiently without assuming the monetary obligations of others and without allowing members to profit from illness or accident. OPL includes coordination of benefits, Medicare, Workers’ Compensation, subrogation, and no-fault auto insurance.

Plan

Refers to any BCBS plan.
 

POS

A health benefit program in which the highest level of benefits is received when the member obtains services from his/her primary care provider/group and/or complies with referral authorization requirements for care. Benefits are still provided when the member obtains care from any eligible provider without referral authorization, according to the terms of the contract

 

Qualified Health Plan (QHP)

Under the Affordable Care Act, which started in 2014, an insurance plan that is certified by an Exchange, provides essential health benefits, follows established limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximum amounts), and meets other requirements. A qualified health plan will have a certification by each Marketplace in which it is sold.

Small Business Health Options Program (SHOP)

Program designed to assist qualified small employers in facilitating the enrollment of their employees in qualified health plans offered in the small group market. The program allows employers to choose the level of coverage and offer choices among health insurance plans. SHOP insurance is generally available to employers with 1-50 employees, but in some states SHOP is available to employers with 1-100 employees.
 

State Children’s Health Insurance Program (SCHIP)

SCHIP is a public program administered by the United States Department of Health and Human Services that provides matching funds to states for health insurance to families with children. The program was designed with the intent to cover uninsured children in families with incomes that are modest but too high to qualify for Medicaid. States are given flexibility in designing their SCHIP eligibility requirements and policies within broad federal guidelines. Some states have received authority through waivers of statutory provisions to use SCHIP funds to cover the parents of children receiving benefits from both SCHIP and Medicaid, pregnant women, and other adults.

 

Traditional Coverage

Provides basic and/or supplemental hospital and medical/surgical benefits (e.g., basic, major medical and add-on riders) designed to cover various services. Such products generally include cost sharing features, such as deductibles, coinsurance or copayments. 

Section 6 - BlueCard® Program Quick Tips

The BlueCard Program provides a valuable service that lets you file all claims for members from other Blue Cross Blue Shield Plans to your local Plan.

Here are some key points to remember:

  • Make a copy of the front and back of the member's ID card.
  • Look for the three-character prefix that precedes the member's ID number on the ID card.
  • Call BlueCard Eligibility at 1-800-676-BLUE to verify the patient's membership and coverage or submit an electronic HIPAA 270 transaction (eligibility) to the local Plan.
  • Submit the claim electronically to Highmark Blue Cross Blue Shield of Western New York. Always include the patient's complete identification number, which includes the three-character prefix.
  • For claims inquiries, call Highmark Blue Cross Blue Shield of Western New York at 1-800-444-2012.