| BlueCard
basics |
| 1. |
What is the
BlueCard® Program?
BlueCard is a national program that enables
members of one Blue Cross and/or Blue Shield Plan
(Blue Plan) to obtain health care services while
traveling or living in another Blue Plan’s
service area. The program links participating
physicians, other health care professionals and
facilities with the independent Blue 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 Blue Plans, domestic
and international, to your local Blue Plan--Regence
BCBSO.
Regence BCBSO is your contact for claims payment,
problem resolution and adjustments.
|
| 2. |
What products are included
in the BlueCard Program?
The BlueCard Program applies to all inpatient, outpatient
and professional claims. This includes traditional,
preferred provider option (PPO), point-of-service
(POS) and Health Maintenance Organization (HMO)
products. |
| 3. |
What benefits are excluded
from the BlueCard Program?
Dental services and prescription medication benefits
are excluded from the BlueCard Program. In addition,
claims for Federal Employee Program (FEP) are exempt
from the BlueCard Program. |
| 4. |
What is the BlueCard Traditional
Program?
A national program that offers members traveling
or living outside of their Blue Plan’s area
traditional or indemnity level of benefits when
they obtain services from a physician, other health
care professional or facility outside of their Blue
Plan’s service area. |
| 5. |
What is the BlueCard Managed
Care/POS Program?
Similar to BlueCard traditional and BlueCard PPO,
BlueCard Managed Care/POS (point-of-service) program
is for members who reside outside their Blue Plan’s
service area. However, unlike other BlueCard Programs,
BlueCard Managed Care/POS members are enrolled in
HMO networks and primary care physician (PCP) panels.
Therefore, you should treat these members as you
treat any other Regence BCBSO Managed Care/POS member,
applying the same referral practices and network
protocols. |
| 6. |
What is the BlueCard PPO
Program?
A national program that offers members traveling
or living outside of their Blue Plan’s area
the preferred provider option (PPO) level of benefits
when they obtain services from a physician, other
health care professional or facility designated
as a BlueCard PPO provider. To find out if you're
a BlueCard PPO provider, visit www.bcbs.com. |
| 
|
| Identifying
Members and ID Cards |
| 1. |
How do I identify members?
When members of Blue Plans arrive in your office
or facility, be sure to ask for their current member
identification (ID) card. The card identifies BlueCard
members with an alpha prefix. The ID cards may also
have:
- A blank suitcase logo
- A PPO in a suitcase logo
- No suitcase logo
|
| 2. |
Why is the alpha prefix so
important?
The alpha prefix is the key element used to identify
members and route out-of-area claims. The alpha
prefix on a member’s ID card is three characters.
(You may see ID cards with four-character alpha
prefixes, e.g., HMSA Blue Cross Blue Shield of Hawaii
uses four-character alpha prefixes).
The alpha prefix identifies the Blue Plan or
national account to which the member belongs.
It is critical for confirming a patient's membership
and coverage. The remaining portion of the member's
ID consists of seven to 14 alpha and/or numeric
characters.
We suggest you make copies of the front and back
of the member's ID card and share this information
with your billing staff.
It's important that you do not add or delete
any alpha/numeric characters in the member's ID
number.
|
| 3. |
What are the various types
of alpha prefixes?
There are two types of alpha prefixes: plan-specific
and account-specific.
Plan-specific alpha prefixes are assigned to
every Blue Plan and start with X, Y, Z, or Q.
The first two positions indicate the Blue Plan
to which the member belongs. The third position
identifies the product in which the member is
enrolled.
- First character X, Y, Z or Q
- Second character A-Z
- Third character A-Z
Account-specific prefixes are assigned to centrally
processed national accounts. National accounts
are employer groups that have offices or branches
in more than one area, but offer uniform benefits
coverage to all of their employees. Account-specific
alpha prefixes:
- Start with letters other than X, Y, Z, or
Q.
- Typically relate to the name of the group.
- Use all three positions to identify the
national account.
|
| 4. |
How do I determine a member's
participation status [traditional, Point-of-Service
(POS), Health Maintenance Organization (HMO) or
Preferred Provider Option (PPO)]?
To determine the member's participation status,
check the suitcase logo.
- A blank suitcase logo on a member's ID card
indicates that the patient has traditional,
POS or HMO benefits delivered through the BlueCard
program.
- A PPO in the suitcase logo indicates the patient
has PPO benefits.
|
| 5. |
How do I identify BlueCard
Managed Care/POS members?
A blank suitcase logo on a member's ID card means
that the patient has traditional, POS or HMO benefits
delivered through the BlueCard Program.
- If members are enrolled in primary care physican
(PCP) panels, the ID card will include an office
visit co-payment, if applicable.
|
| 6. |
How do I identify BlueCard
PPO members?
You'll immediately recognize the BlueCard PPO members
by the special "PPO in a suitcase" logo
on their ID card. BlueCard PPO members are members
of Blue Plans with PPO benefits, delivered through
the BlueCard Program. It's important to remember
that not all PPO members are BlueCard PPO members,
only those whose ID cards carry this logo.
- BlueCard PPO members traveling or living outside
of their Blue Plan's service area receive the
PPO level of benefits when they obtain services
from designated BlueCard PPO physicians, other
health care professionals or facilities.
|
| 7. |
What if a member has an ID
card without an alpha prefix?
This indicates that claims are exempt from the BlueCard
Program (i.e., claims for dental and prescription
medications and FEP members). Please look for instructions
or a telephone number on the back of the member's
ID card. |
| 8. |
What if a member has an ID
card with an alpha prefix but no suitcase logo?
If the member's ID card has an alpha prefix (with
or without a suitcase logo), send it to your local
Blue Plan--Regence BCBSO. It will be paid at the
member's Blue Plan's allowable. You will receive
any reimbursement from your local plan. |
| 9. |
How do I identify international
members?
Occasionally, you may see identification cards from
international Blue Plan members. These ID cards
will also contain three-character alpha prefixes.
The claim process for international claims is the
same as domestic claims. Please submit these claims
to your local Blue Plan--Regence BCBSO. |
|
| Verifying
eligibility and coverage |
| 1. |
How do I verify membership
and coverage?
For members of other Blue Plans, you may verify
membership and coverage by phone or by submitting
electronic inquiries.
Phone: Call the telephone number on
the back of the member's ID card. If that information
is not available, call BlueCard Eligibility®
at 1 (800) 676-BLUE (2583). You will be prompted
for the member's alpha prefix and connected to
the appropriate Blue Plan.
Electronic inquiry: Submit a HIPAA 270
transaction (eligibility) to Regence BCBSO. The
majority of BlueCard electronic inquiries are
answered within 48-72 hours (Monday through Friday
during regular office hours).
|
| 2. |
What benefits and claims
are exempt from the BlueCard Program?
Dental and prescription medication benefits are
exempt from the BlueCard Program. In addition, claims
for the Federal Employee Program (FEP) are exempt
from the program. |
|
| Pre-authorizations
|
| 1. |
How do I obtain pre-certifications
and/or pre-authorization?
You should remind patients from other Blue Plans
that they are responsible for obtaining pre-certification/pre-authorization
for their services from their Blue Plan. Please
note: Other Blue Plan's pre-authorization lists
may differ from Regence BCBSO's.
You may also choose to contact the member's Blue
Plan on behalf of the member by phone or by submitting
electronic inquiries.
Phone-Call the telephone number on the
back of the member's ID card or BlueCard Eligibility
at 1 (800) 676-BLUE (2583). You will be prompted
for the member's alpha prefix and connected to
the appropriate Blue Plan. Ask to be transferred
to the utilization review area.
Electronic inquiry-Submit a HIPAA 278
transaction (referral/authorization) to Regence
BCBSO. The majority of BlueCard electronic inquiries
are answered within 48-72 hours (Monday through
Friday during regular office hours).
|
|
| Filing
claims |
| 1. |
Where and how do I submit
claims?
Submit BlueCard claims electronically with your
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. Incorrect
or missing alpha prefixes and ID numbers delay
claims processing. Do not send duplicate claims.
|
| 2. |
How do I submit international
claims?
The claim submission process for international Blue
Plan members is the same as for domestic Blue Plan
members. You should submit the claim directly to
Regence BCBSO. |
| 3. |
How do I submit claims
if I'm an indirect, support or remote provider?
If you are an indirect, support or remote health
care professional or facility 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.
|
| 4. |
What are the 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 submit the claim to us
electronically or send the paper claim to us at:
Regence BlueCross BlueShield of Oregon
P.O. Box 30805
Salt Lake City, UT 84130-0805
Please note: Occasionally you may be asked to
submit BlueCard claims directly to the member's
Blue Plan. For instance, there may be a temporary
processing issue at Regence BCBSO or the member's
Blue Plan or both that prevents completion of
claims through the BlueCard Program.
|
| 5. |
How do I handle Coordination
of Benefit (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 cross-over.
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 cross-over.
Please note: If you do not include the EOB information
with the claim, the claim will need to be investigated.
This investigation could delay your payment or
result in a post-payment adjustment.
|
| 6. |
How do I handle Medicare-related
claims?
Blue Plan is primary
Submit claims to your local Blue Plan--Regence
BCBSO. Do not bill Medicare directly for any services
rendered to a Medicare Advantage member.
Medicare is primary
When Medicare is the primary payer for an out-of-area
Blue Plan member (e.g., Medigap plans), follow
these procedures:
- Submit claims to your local Medicare contractor
first. Do not file with Medicare and the supplemental
insurer simultaneously. Be sure to include the:
a) complete Health Insurance Claim Number
(HICN),
b) patient's complete ID number,
c) patient's name as it appears on the card.
d) Other carrier’s name and address
(OCNA) number. If you include this information,
make sure it is the correct OCNA for the member’s
plan.
- 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.
|
| 7. |
How will I receive payment?
- Once Regence BCBSO receives a claim, we will
price the claim based on your contract with
us (participating or preferred) and electronically
route the claim to the member's Blue Plan.
- The member's Blue Plan adjudicates the claim
and approves payment based on the member's benefits:
- 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
option (PPO) level of 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. To find out if you're a BlueCard
PPO provider, visit www.bcbs.com.
It's important to note that not all PPO
members are BlueCard PPO members, only members
whose ID cards carry this logo. If you
are a non-PPO provider, you will receive participating
provider rates.
- Regence BCBSO will reimburse you accordingly
and provide information on your payment voucher.
|
|
