May 2012 Newsletter
BlueCard Program
The Blue Cross and Blue Shield Association has announced a change to their BlueCard® Program’s claim filing rules for ancillary providers, such as Independent Clinical Laboratories. Effective no later than October 2012, this change is to be implemented for all Blue Cross Blue Shield (BCBS) plans, with the exception of the Federal Employee Program (FEP). Individual BCBS plans are to begin enforcing claim filing rules over the coming months.
BCBS plans are considered Host plans (also referred to as local plans) or Home plans. The local Host plan is the BCBS plan in the area the laboratory is located. The Home plan is the plan the member is enrolled in. Generally, using the BlueCard Program, claims are filed with the laboratory’s local Host plan when the lab does not have contract coverage with the patient’s Home plan. The Host plan accepts the claim and sends it to the Home plan for the adjudication process. Under the new BlueCard Program policy, independent laboratories will be required to submit claims to the BCBS Plan in whose state the test specimen was collected, whether or not there is contract coverage. The state in which the ordering/referring provider is located is used to determine the correct Host Plan. For states with multiple Plans, the laboratory can choose which Plan to send the claim. If the laboratory performs a high volume of tests on specimens drawn outside the state where their lab is located, current reimbursement rates may be affected as your local Host BCBS Plan will no longer be receiving a majority of the claims.
Member's Home Plan |
Independent lab’s local Host Plan |
Where specimen was drawn (i.e. state where ordering/referring provider is located) |
Where claim should be filed |
BCBS of AL |
BCBS of ND |
Kentucky |
BCBS of KY |
BCBS of AL |
BCBS of ND |
California |
Either Anthem BC (CA) or Blue Shield of CA |
BCBS of ND |
BCBS of ND |
Hawaii |
BCBS of HI |
Information on the requirements of the new BlueCard Program claim filing rules have been difficult to gather given that advisories are published by each individual BCBS Plan and not all Plans have issued notices or implementation details. Quadax continues to actively monitor information about the changes as they become available. We are also developing tools in our HARP and PAS applications to manage the claim routing to meet the requirements of the BlueCard Program using the NPI of the ordering physician to determine the Host plan in effect for that state. Watch for release notes announcing these new tools.