BlueCard^® Provider Manual

Filing claims

Coding
Code claims the same way you do your other Regence BCBSO claims.

Claims submission
You should always submit claims electronically with other Regence BCBSO claims or send paper claims to:

Regence BlueCross BlueShield of Oregon
P.O. Box 30805
Salt Lake City, UT 84130-0805

Be sure to include the member's complete ID number when you submit the claim. The complete ID number includes the three-character alpha prefix. It's important that you do not add or delete any alpha/numeric characters to the member's ID number. Claims with incorrect or missing alpha prefixes and member ID numbers delay claims processing.

Do not send duplicate claims.

International claims
The claim submission process for international Blue Plan claims is the same as domestic Blue Plan claims. You should submit the claim directly to Regence BCBSO.

Exceptions to BlueCard claims submissions
Submit claims directly to the member's Blue Plan instead of Regence BCBSO in the following situations:

• You contract with the member's Blue Plan.
• The member's ID card does not include an alpha prefix.
• The benefits are excluded from the BlueCard Program (e.g., dental and prescription medications).
• The member belongs to the Federal Employee Program (FEP) - please follow your FEP guidelines.

When in doubt, please send the claim to us electronically or send the paper claim to us at the address listed above.

Indirect, support or remote providers
If you are an indirect, support or remote provider for members from multiple Blue Plans, follow these claim-filing procedures:

• If you have a contract with the member's Blue Plan, file with that Plan.
• If you normally send claims to the direct provider of care, follow normal procedures.
• If you do not normally send claims to the direct provider of care and you do not have a contract with the member's Blue Plan, file with your local Blue Plan--Regence BCBSO.

If you are a health care professional or facility that offers products, materials, informational reports and remote analyses or services, and are not present in the same physical location as a patient, you are considered an indirect, support, or remote provider. Examples include, but are limited to:

• prosthesis manufacturers,
• durable medical equipment suppliers,
• independent or chain laboratories, or
• telemedicine providers.

Other Party Liability

Other Party Liability (OPL) is a cost containment program that recovers money where primary responsibility does not exist because of another group health plan or contractual exclusions. OPL includes worker’s compensation, subrogation and no-fault auto insurance.

In cases where a third party is involved, submit OPL information with the Blue Plan claim to Regence BCBSO. Upon receipt, Regence BCBSO will electronically route the claim to the member’s Blue Plan. The member’s Blue Plan will then process the claim and approve any payment based on the member’s benefits. Regence BCBSO will reimburse you accordingly and provide information on your payment voucher.

Coordination of Benefits (COB) claims
Coordination of Benefits (COB) refers to how we ensure members receive benefits while preventing double payment for services when a member has coverage from two or more payers. The member's contract language explains which payer has primary responsibility for payment. Please follow the procedures below for submitting COB claims.

Member has coverage with two out-of-area Blue Plans

• Send the claim to Regence BCBSO with the primary member ID first.
• After you receive the Explanation of Benefits (EOB), send the information with a new bill to Regence BCBSO for secondary payment. The claim will not automatically crossover.

Another carrier is the primary payer and a Blue Plan is secondary

• Bill the other carrier first.
• Send the EOB from the other carrier with the claim to Regence BCBSO for secondary payment. The claim will not automatically crossover.

Please note: If you do not include the EOB information with the claim, the claim will need to be investigated. An investigation could delay your payment or result in a post-payment adjustment.

Medicare Crossover claims
If you accept Medicare assignment and render services to members from other Blue Plans, please note the following.

Medicare is primary
When Medicare is the primary payer for an out-of-area Blue Plan member (e.g., Medigap plans), follow these procedures:

1. Submit claims to your local Medicare contractor first. Do not file with Medicare and the supplemental insurer simultaneously. Be sure to include the:
   • complete Health Insurance Claim Number (HICN),
   • the patient's complete ID number, and
   • patient's name as it appears on the card.
   • Other carrier’s name and address (OCNA) number. If you include this information, make sure it is the correct OCNA for the member’s Blue Plan.
2. After you receive an Explanation of Medical Benefits (EOMB) or Medicare Remittance Notice (MRN), determine if the claim was automatically crossed over to the supplemental insurer:

• Crossed over: If the indicator on the EOMB or MRN shows that the claim was crossed-over (claim status code 19: “Medicare paid primary and the Intermediary sent the claim to another insurer”), Medicare has forwarded the claim on your behalf to the appropriate Blue Plan and the claim is in process. You do not need to file for the Medicare supplemental benefits. The Medicare supplemental insurer will automatically pay you, if you accepted Medicare assignment. Otherwise, the member will be paid and you will need to bill the member.
• Not crossed over: If the EOMB or MRN does not indicate the claim was crossed over (claim status code 1: “Paid as primary” may appear; claim status 19 will not appear), file the claim as you do today to Regence BCBSO. Regence BCBSO or the member's Blue Plan will pay you the Medicare supplemental benefits. If you did not accept Medicare assignment, the member will be paid and you will need to bill the member.

Blue Plan is primary
When a Blue Plan is the primary payer (e.g., Medicare Advantage) and Medicare is secondary, submit claims to Regence BCBSO. Do not bill Medicare directly for any services rendered to a Medicare Advantage member.

Medicare Advantage reimbursement
Based on the Centers for Medicare and Medicaid (CMS) regulations, if you are a provider who accepts Medicare assignment and renders service to Medicare Advantage members from other Blue Plans, you will be reimbursed the equivalent of the current Medicare allowable amount for all covered services. This amount may be less than your charge amount. CMS regulations state that the Medicare allowable amount is considered payment in full.

Other than the applicable member cost sharing amounts, reimbursement is made directly by the Blue Plan. You may collect only the applicable cost sharing (i.e., copayment) amounts from the member at the time of service, and may not otherwise charge or balance bill.

Medical records
There are times when the member's Blue Plan will require medical records to review the claim. When resolution of claim suspensions requires additional information from you, Regence BCBSO may either ask you for the information or give the member's Blue Plan permission to contact you directly.

Please forward all requested medical records to Regence BCBSO and we will coordinate with the member's Blue Plan.

Please do not proactively send medical records with the claim, unless requested. Unsolicited claim attachments may cause claim payment delays.

Claims status
You can check the status of a BlueCard claim by phone or by submitting an electronic inquiry.

Phone: If you have BlueCard claims-related questions, call Regence BCBSO's BlueCard Provider Customer Service at 1 (800) 448-0525 or in Portland at (503) 225-5393.

Electronic Inquiries: To check the status of a BlueCard claim, submit a HIPAA 276 transaction (claims status request) to Regence BCBSO. The majority of BlueCard electronic inquiries are answered within 48-72 hours (Monday through Friday during regular business hours).

Claims payment process

1. Member of another Blue Plan receives services from you.
2. You submit the claim to Regence BCBSO. Regence BCBSO determines your (physician, other health care professional or facility’s) network participation, either participating or preferred.
3. Regence BCBSO transmits the claim to the member’s Blue Plan.
4. The member’s Blue Plan:
   1. Determines and/or applies pre-authorization requirements, medical policies and any state mandates. Adjudicates the claim according to the member’s benefits and sends this information to Regence BCBSO.
   2. Issues an Explanation of Benefits (EOB) to the member.
5. Regence BCBSO sends a payment voucher to you.
   

If you haven't received payment, do not resubmit the claim. If you do, the claim may be denied as a duplicate. The member will also receive another Explanation of Benefits (EOB). Please understand that the timing of claims processing varies at each Blue Plan. The standard time for non-investigational claims processing at Regence BCBSO is 20 business days from the time the claim is received in our office.

Rates

Member's ID card has an empty suitcase logo. The member has traditional, Point-of-Service (POS), or Health Maintenance Organization (HMO) benefits and you will be reimbursed at participating provider rates.

Member's ID card has a PPO in the suitcase logo. The member has Preferred Provider Organization (PPO) level benefits when they obtain services from a physician or hospital designated as a BlueCard PPO provider. If you are a BlueCard PPO provider, you will be reimbursed at preferred provider rates. If you are a non-PPO provider and care for a PPO member, you will be reimbursed at participating provider rates. It's important to note that not all PPO members are BlueCard PPO members, only members whose ID cards carry this logo.

Adjustments
Contact Regence BCBSO if a claim adjustment is required. We will work with the member's Blue Plan for adjustments.

• Call Regence BCBSO's BlueCard Customer Service at 1 (800) 448-0525 or in Portland at (503) 225-5393.
• A Customer Service specialist will check on the status of the original claim and provide you with a contact name and fax number to use when submitting the corrected claim.
• The corrected claim will be personally handled, and the Customer Service specialist will call you with an update on the progress of the claim after ten days, unless payment was sent.

Appeals
Appeals for all claims are handled through Regence BCBSO. We will coordinate the appeal process with the member's Blue Plan, if needed. See the Member Grievance Policy in your Regence BCBSO Provider Handbook.