August 2012 Newsletter
BlueCard Program Update for Independent Labs
When the Blue Cross and Blue Shield Association (BCBS) announced new claim filing rules for its BlueCard® program, which impacts ancillary providers such as independent laboratories, Quadax began developing the software updates needed for the claim routing requirements. The implementation of this new program is being handled uniquely by each Blue plan, and plans may institute the program on different dates. We first began researching the effective dates as well as the provider registration requirements for each BCBS plan, and then developed a comprehensive list of conversion dates, registration requirements, electronic transmission requirements, and contact information for every Blue plan in the U.S.
Under the new filing rules, the previous coordination of claim submission, adjudication, and payment between a lab’s local Host Blue plan and a patient’s Home Blue plan will no longer occur if a lab receives specimens from outside the state. The coordination will now be between the patient’s Home plan and the Host plan in effect where the specimen was drawn, which may involve many plans a lab has not previously dealt with. To assist our clients with the daunting task of registering with the expanded number of Blue plans to which they will need to send claims, Quadax is offering provider registration services for those clients who request it. The Quadax EDI clearinghouse has established connections with nearly all Blue plans in the country, and our Quadax Account Executives are gathering Electronic Claim Registration forms for Blue plans new to their clients so claims can be submitted electronically, ensuring that all claims are efficiently processed.
Quadax recently implemented new versions of our software to comply with the BlueCard requirements. In anticipation of claim routing issues and increased complexity with claim submission and payment, we have also developed processes for our HARP and PAS Manager clients to quickly identify and resolve claim denials and rejections due to this rule change.
HARP, our Revenue Cycle Management application, will now route claims for independent laboratories to the BCBS Host plan in the referring physician's state instead of submitting them to the patient's Home plan. The claim routing is based on new client-level tables in HARP specifically for the BlueCard program. The initial claim will be generated with the billed insurance as the patient’s Home plan, but the claim will be sent to the Host plan in effect where the specimen was drawn, based on the referring physician's state and values in the client-level tables. The claim rerouting occurs in our nightly Insurance Processing when electronic and hardcopy claims are actually created. Tickets in HARP will show both the patient's Home plan and the Host insurance plan to which a claim was submitted.
Example of section of the Inquiry page in HARP
PAS, our Reimbursement Support Services application, has also been updated to accommodate the BlueCard claim filing rules. Processes that occur prior to the claim (e.g., Data Verification, Eligibility, and Benefit Investigation) will continue to use the patient’s Home plan. However, claims and post-claim processes, such as appeals, will use the referring provider’s Host plan. When a claim is rerouted to the Host plan, information for that plan will be added to PAS during PAS/HARP synchronization and will be listed beneath the patient’s Home plan as the rerouted insurance. The table below shows some examples of the BCBS plan that will be used for various functions in PAS and HARP.
More details on how HARP and PAS are handling BlueCard claims can be found in the release notes, and further information on the BlueCard program is in the May issue of the Quadax newsletter. As always, Quadax will continue to stay on top of new industry requirements and make the necessary changes to our applications to conform to them.