Host Plan roles and responsibilities to Independence network providers

Independence, as your local Blue Cross and/or Blue Shield Plan (Host Plan), has roles and responsibilities when you render services to an out-of-area member (i.e., member enrolled in another Blue Cross and/or Blue Shield Plan), including provider-related functions such as:

• being the single contact for all claims payment, customer service issues, provider education, adjustments, and appeals;
• pricing claims and applying pricing and reimbursement rules consistent with provider contractual agreements;
• forwarding all clean claims received to the member?s Blue Cross and/or Blue Shield Plan (Home Plan) to adjudicate based on eligibility and contractual benefits;
• conducting appropriate provider reviews and/or audits;
• confirming that providers are performing services and filing claims appropriately within their scope of practice and according to their Provider Agreement with Independence;
• conducting HIPAA-standard transactions;
• training providers about the BlueCard Program.

Home Plan roles and responsibilities to Independence network providers

The Home Plan has roles and responsibilities when you, the local Independence network provider, render services to an out-of-area member, including the following functions:

• adjudicate claims based on member eligibility and contractual benefits;
• respond to prior authorization and precertification requests/inquiries;
• request medical records through the Host Plan when required (e.g., for review of medical necessity, determination of a pre-existing condition, high-cost/utilization).

Roles and responsibilities of Independence network providers

You, the local Independence network provider, have the following roles and responsibilities when you render services to an out-of-area member:

• obtaining benefits and eligibility information, including covered services, copayments, and deductible requirements;
• filing claims with the correct Host Plan and including, at minimum, the required elements to ensure timely and correct processing, such as:
  • – current member ID card number;
  • – all Other Party Liability information;
  • – all member payments (i.e., copayments, coinsurance, or deductibles);
• submitting medical records in a timely manner when requested by the Host or Home Plan.