BlueCard is a national program offered through the Blue Cross and Blue
Shield Association (BCBSA), an association of independent Blue Cross? and Blue Shield? plans, that enables members of one Blue Plan
to obtain health care benefits and services while traveling or living in
another Blue Plan?s service area. The BlueCard program provides coverage for
members by linking participating health care providers through a single
electronic network for claims processing and reimbursement. This extensive
network provides coverage to members travelling in the U.S. and in
approximately 170 countries and territories worldwide.
Standardized claims filing guidelines were implemented in 2012 for
independent clinical laboratories (lab), durable medical equipment (DME)
providers, and specialty pharmacies.
Note: These billing guidelines do not apply to claims submitted for
Federal Employee Program (FEP?) members. For more information about
FEP claims filing guidelines, please refer to the FEP website.
Ancillary providers contracted with
Independence
Lab (non-hospital based):
How to file (required fields)
Where to file
Referring Provider:
- Field 17 with qualifier DN on CMS-1500 form, or
- Loop 2310A (claim level) on 837P (Professional Electronic
Submission)
File the claim with the Plan local to the area in which the specimen was
drawn. For states with multiple Blue Plans, the state or county in which the
referring provider is located will determine where the specimen is drawn.
Example:
- If an Independence member has a specimen drawn and the referring
provider is contracted with Independence, the lab provider must file the claim
with Independence.
- If a BlueCard member has a specimen drawn in the five-county Philadelphia
region, the lab provider must file the claim with Independence.
- If a BlueCard member has a specimen drawn outside the five-county
Philadelphia region, the lab provider must file the claim with the Plan local
to the area in which the specimen was drawn.
DME:
How to file (required fields)
Where to file
Patient?s Address:
- Field 5 on CMS-1500, or
- Loop 2010CA on 837P
Ordering Physician:
- Field 17 with qualifier DK on CMS-1500, or
- Loop 2420E (line level) on 837P
Place of Service:
- Field 24B on CMS-1500, or
- Loop 2300, CLM05-1 on 837P
Service Facility Location Information:
- Field 32 on CMS-1500, or
- Loop 2310C (claim level) on 837P
File the claim with the Plan local to the service area in which the DME
supplies were shipped or received.
Example:
- For an Independence member, the DME supplier must file the claim with
Independence regardless of where DME supplies were shipped or received.
- If a BlueCard member has DME supplies shipped to or received at a location
in the five-county Philadelphia region, the DME supplier must file the claim
with Independence.
- If a BlueCard member has DME supplies shipped to or received in a location
outside the five-county Philadelphia region, the DME supplier must file the
claim with the Plan local to the area in which the DME supplies were shipped or
received.
Specialty Pharmacy (non-routine,
biological therapeutics ordered by a health care professional as a covered
medical benefit as defined by the Plan?s Specialty Pharmacy
formulary):
How to file (required fields)
Where to file
Referring Provider:
- Field 17B on CMS-1500 form, or
- Loop 2310A (claim level) on 837P
For states with multiple Blue Plans, file the claim with the Plan local to
the state or county of the ordering physician.
Example:
- For an Independence member, regardless of where the referring
(ordering) physician is located, the specialty pharmacy provider must file the
claim with Independence.
- If a BlueCard member uses a specialty pharmacy and the referring (ordering)
physician is in the five-county Philadelphia region, the specialty pharmacy
provider must file the claim with Independence.
- If a BlueCard member uses a specialty pharmacy and the referring (ordering)
physician is outside of the five-county Philadelphia region, the specialty
pharmacy provider must file the claim with the Plan local to the area of the
ordering physician.
Ancillary providers who are not contracted
with Independence or any other Blue Plan
Lab:
For Independence or any other BlueCard member, the lab provider must file
the claim with the Plan local to the service area in which the specimen was
drawn.
DME:
For Independence or any other BlueCard member, the DME supplier must file
the claim with the Plan local to the service area in which the DME supplies
were shipped or received.
Specialty Pharmacy:
For Independence or any other BlueCard member, the specialty pharmacy
provider must file the claim with the Plan local to the referring (ordering)
physician?s service area.
Note: The claim is considered a nonparticipating provider claim since
the ancillary provider does not have a contract with Independence or any other
Blue Plan.
Ancillary providers contracted with a Blue
Plan other than Independence
If you are contracted with a Blue Plan other than Independence,
always file claims with that Blue Plan for services rendered to that Plan?s
enrollees. In addition, you should file claims for services rendered to any
other BlueCard member in your contracted Blue Plan?s service area to that Blue
Plan. For example, a provider contracted with Horizon Blue Cross and Blue
Shield (Horizon) should file claims for a BlueCard member with Horizon.
Lab:
File claims for any other BlueCard member with Horizon for specimens drawn
in New Jersey.
DME:
File claims for any other BlueCard member with Horizon for DME supplies
shipped to or received in New Jersey.
Specialty Pharmacy:
File claims for any other BlueCard member with Horizon when the referring
(ordering) physician is located in New Jersey.
If services are rendered to Blue Plan members who are not enrolled with your
contracted Blue Plan, or for services rendered outside your contracted Blue
Plan's service area, you should file claims according to the guidelines listed
below. These claims will be considered nonparticipating claims.
Lab:
File claims with the Plan local to the service area in which the specimen
was drawn.
DME:
File claims with the Plan local to the service area in which the DME
supplies were shipped or received.
Specialty Pharmacy:
File claims with the Plan local to the ordering physician?s service
area.
More information
For more information
about the BlueCard Program, visit the BlueCard section.
Independence Blue Cross is an independent licensee of the
Blue Cross and Blue Shield Association.