BlueCard Program Manual for Florida Physicians and Providers
What to do when you see a Patient with Out-of-Area Blue Plan Coverage
Note: In the event of any inconsistency between information contained in this manual and the agreement(s) between you and Florida Blue, the terms of such Agreement(s) shall govern. Also, please note that Florida Blue and other Blue Cross and/or Blue Shield plans, may provide available information concerning an individual’s status, eligibility for benefits, and/or level of benefits. The receipt of such information shall in no event be deemed to be a promise or a guarantee of payment, nor shall the receipt of such information be deemed to be a promise or guarantee of eligibility of any such individual to receive benefits. Further, presentation of Florida Blue identification cards in no way creates, nor serves to verify an individual’s status or eligibility to receive benefits. In addition, all payments are subject to the terms of the contract under which the individual is eligible to receive benefits.
As a Florida Blue participating provider, you may render services to patients who have health care coverage with another Florida Blue Plan (Blue Plan). This manual provides you with BlueCard® Program administrative guidelines and explains policies, billing and payment processes and requirements. It offers helpful information about:
The most current version of this manual is available on the Florida Blue website, www.floridablue.com
About the BlueCard Program
BlueCard is a national program that enables members to obtain health care services while traveling or living in another Blue Plan’s service area. It applies to all covered inpatient, outpatient and professional health care services. The program links participating health care providers with 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 lets you submit claims for patients from other Blue Plans, domestic and international, to Florida Blue. We are your sole contact for claims payment, adjustments and issue resolution.
The Home Plan is the Blue Plan in the state where the subscriber/member lives, or where the group/contract is headquartered. Members receive the benefits of their Home Plan contract. The Host Plan refers to the Blue Plan of the service area away from the member’s home where services are rendered.
In Florida, the BlueCard Program applies to physicians and providers participating in Florida Blue’s Preferred Patient Care (PPC) and/or Payment for Professional Services (PPS)/Payment for Hospitals Services (PHS)/Traditional participation programs.
Advantages for Physicians and Providers
BlueCard advantages include:
Streamlined claim billing and administration. You file claims for members from other Blue Plans directly to Florida Blue.
A single point of contact for claim inquiries – Florida Blue at (800) 727-2227.
Direct payment from Florida Blue based on your negotiated agreement.
One telephone number to call for eligibility information – BlueCard Eligibility at (800) 676-BLUE (2583) which connects you directly with the member’s Plan.
Members can easily find participating physicians and providers by calling the BlueCard telephone number on their ID card or visiting the Blue Cross and Blue Shield Association (BCBSA) website at www.bcbs.com.
Products Included in BlueCard Program
The BlueCard Program applies to a variety of products. Although Florida Blue may not offer all these to our members, you may see members from other Blue Plans who are enrolled in these other products:
Preferred Provider Organization (PPO)
Exclusive Provider Organization (EPO)
Point of Service (POS)
HMO (Health Maintenance Organization)*
Medicaid (Payment is limited to the member’s Plan’s state Medicaid reimbursement rates. These ID cards do not have a suitcase logo.)
State Children’s Health Insurance Plan (SCHIP) (If administered as part of Medicaid - payment is limited to the member’s Plan’s state Medicaid reimbursement rates. These ID cards do not have a suitcase logo. Standalone SCHIP programs will have a suitcase logo.)
Standalone prescription drugs
*For HMO members, the BlueCard Program only applies to members traveling outside their Blue Plan’s service area.
Note: Standalone vision and standalone self-administered prescription drugs programs are eligible to be processed through BlueCard when such products are not delivered using a vendor. Consult claim filing instructions on the back of the ID cards.
Products Excluded from BlueCard Program
The following products and/or groups are excluded from the BlueCard Program:
*Medicare Advantage is a separate program from BlueCard; however, since you might see members with Medicare Advantage coverage from other Blue Plans, we have included a section on Medicare Advantage claims processing
in this manual.
When you provide services to a member who has coverage with another Blue Plan but the BlueCard Program does not apply, file the claim to Florida Blue as long as the member ID number includes an alpha prefix. You may file electronically or send a paper claim.
Florida Blue will forward the claim to the member’s Blue Plan for processing and payment. Be sure to submit the correct alpha prefix.
Florida Blue will send a letter advising you that your claim has been forwarded. The remittance advice and payment may be sent to either the member or the provider.
Claim inquiries should be directed to Florida Blue at (800) 727-2227.
When the BlueCard Program does not apply, your contractual agreement with Florida Blue may not apply. In such cases, you may elect to bill the member upfront.
How to Identify Members
Member ID Cards
When members of Blue Plans arrive at your office or facility, always ask for their current ID card.
A ”suitcase” logo on the member’s ID card indicates the BlueCard Program applies.
An alpha prefix (3-letter prefix at the beginning of the ID number) identifies the member’s Blue Plan or national account.
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A “PPO” inside the logo indicates the member is enrolled in either a PPO or EPO product. These members use the PPO network for the lowest out-of-pocket costs; in Florida that is Florida Blue’s PPC network. PPO members may also use the Traditional/PPS/PHS network, but will usually have higher out-of-pocket costs. Please note, however, that EPO products may have limited benefits out-of-area. Refer to the member’s ID card for information.
Note: The PPC network is the default BlueCard Host network. If a member is accessing NetworkBlue, the NetworkBlue name will be on the front of the ID card in the “Blue Product” area.
An empty/blank suitcase logo indicates the member is enrolled in a Traditional, POS or HMO product. These BlueCard members use the Traditional/PPS/PHS network while in Florida.
Some ID cards do not have a suitcase logo on them. Those are the ID cards for Medicaid, SCHIP, and Medicare Complementary and Supplemental products, also known as Medigap. Government-determined reimbursement levels apply to these products. While Florida Blue routes all of these claims to the member’s Blue Plan, most of the Medicare Complementary or Medigap claims are sent directly from the Medicare intermediary to the member’s Plan via the established electronic crossover process.
To verify if the BlueCard program applies, call BlueCard Eligibility at (800) 676-BLUE (2583).
Occasionally, you may see ID cards from BlueWorldwide Expat members or international Blue Plan members. International Blue Plans include: BCBS of U.S. Virgin Islands, BCBS of Uruguay and BCBS of Panama. BlueWorldwide Expat provides medical coverage for employees of U.S.-based companies doing business abroad. Members enrolled in the BlueWorldwide Expat product are covered in the U.S. for visits of up to 45 days.
These members access the networks of Blue Plans when in the U.S. ID cards also contain a three-character alpha prefix. Please treat these members the same as domestic Blue Plan members. Submit all claims from international or BlueWorldwide Expat members to Florida Blue.
Note: Claims for members of the Canadian Blue Cross Plans are not processed through the BlueCard Program. Follow the instructions listed on the ID card. These plans include: Alberta Blue Cross, Atlantic Blue Cross Care, Manitoba Blue Cross, Pacific Blue Cross, Quebec Blue Cross and Saskatchewan Blue Cross.
Sample International ID Card
Sample of BlueWorldwide Expat ID Card
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Sample Stand Alone Health Care Debit Card
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Sample Combined Health Care Debit Card and Member ID Card
The cards include a magnetic strip so providers can swipe the card at the point of service to collect the member cost sharing amount (i.e., copay, coinsurance, deductible). The funds will be deducted automatically from the member’s appropriate HRA, HSA or FSA account. Members can use their card to pay outstanding balances.
With health debit cards, members can pay for copayments and other out-of-pocket expenses by swiping the card though any debit card swipe terminal. The funds will be deducted automatically from the appropriate member’s HRA, HSA or FSA account.
If your office currently accepts credit card payments, there is no additional cost or equipment necessary. The cost to you is the same as what you pay to swipe any other signature debit card.
Carefully determine the member’s financial responsibility before processing payment. You can access the member’s accumulated deductible by calling the BlueCard Eligibility line at (800) 676-BLUE (2583) or by using the Availity Health Information Network.
If the member presents a debit card (stand-alone or combined), be sure to verify the out of pocket amounts before processing payment:
Many Plans offer well care services that are payable under the basic health care program. If you have any questions about the member’s benefits or to request accumulated deductible information, please call (800) 676-BLUE (2583).
You may use the debit card for member responsibility for medical services provided in your office.
You may choose to forego using the debit card and submit the claims to Florida Blue for processing. The remittance advice will inform you of the member’s responsibility.
All services, regardless of whether or not you’ve collected the member responsibility at the time of service, must be billed to Florida Blue for proper benefit determination, and to update the member’s claim history.
Do not use the card to process full payment upfront. If you have any questions about the member’s benefits, please call (800) 676-BLUE (2583), or for questions about the health care debit card processing instructions or payment issues, call the toll-free debit card administrator’s number on the back of the card.
Limited Benefits Products
Verifying Blue members’ benefits and eligibility is now more important than ever, since new products and benefit types entered the market. In addition to members with traditional PPO, HMO, POS or other coverage, which typically has a high lifetime coverage limit of $1 million or more, you may now see members whose annual benefits are limited to $50,000 or less.
Members who have Blue limited benefits coverage carry ID cards that contain the following information:
Either of two product names — InReach or MyBasic
A tagline in a green stripe at the bottom of the card
A black cross and/or shield to help differentiate it from other identification cards
Sample Limited Benefits ID Cards
When you verify eligibility and benefits, both electronically and via phone, you will receive the member’s accumulated benefits. This will help you understand the remaining benefits for the member.
If the cost of services extends beyond the benefit coverage limit, inform the member of any additional liability.
Electronic Transactions - Availity Health Information Network
To access the following HIPAA-AS compliant e-transactions, Florida physicians and providers must be connected to the Availity Health Information Network. If you do not have access to the Availity Health Information Network, register online at www.availity.com
. The Availity Health Information Network provides the electronic gateway for electronic transactions to Florida Blue. The following e-transactions are available:
Hours of availability for Florida Blue e-transactions are:
Monday through Saturday 12 a.m. – 11 p.m., Eastern Time
Sunday 12 a.m. – 5 p.m., Eastern Time
Occasional system maintenance may affect hours of availability. If the system is unavailable, the Availity website will display an announcement.
Delayed Response for e-Transactions
For Blue Plans that operate in batch-mode or when their real-time system is not available, you will need to retrieve information on the Eligibility and Benefits Inquiry, Health Care Services Review Request, Claim Status Inquiry e-transactions from the Delayed Response Application in the Availity Health Information Network.
Note: To use the Delayed Response Application, you must have the Microsoft Internet Explorer browser.
Steps for Accessing the Delayed Response Application
Select the Delayed Response option on the navigation bar located on the left side of the Availity screen.
Choose the appropriate transaction:
First select “Other Blue Plans” as the payer, then select the appropriate Organization. Click on Submit.
Through a pop-up window, you will link to the Florida Blue website to access the delayed responses from other Blue Plans.
Enter the Subscriber ID number or the Submission Date. This creates a listing that only the requesting provider can view. Click on the blue hypertext to access detailed information.
To exit from the Florida Blue website, close out the separate Florida Blue pop-up window. You will be returned to the Availity screen from where you started.
There is no print capability option for the delayed response information. Therefore, if you need a paper copy, print the page you are viewing using the browser print option.
Eligibility and benefit information and claim status should be available within 24-48 hours. Non-urgent health care services review requests should be available within 1-14 days of submission. For urgent health care services requests, please call the telephone number on the member’s ID card. Response time may also be affected by holiday closings.
The delayed response listings will be available in the mailbox indefinitely.
Eligibility and Benefits
Eligibility and benefit information can be obtained electronically through the Availity Health Information Network or by phone.
Electronic – Submit a HIPAA 270 Transaction (Eligibility)
Enter the member’s first and last name, date of birth, ID number, including alpha prefix, as it appears on the ID card, and relationship to subscriber. Do not add asterisks (*), hyphens (-), periods or spaces to the member ID number. The alpha prefix is required to route the request to the appropriate plan.
If the member’s ID number does not have an alpha prefix, you cannot submit this request electronically. Call the customer service number on the member’s ID card.
Blue Plans will provide the following minimum level of information on an eligibility and benefit response: patient name, date of birth, gender, insurance type code (i.e., PPO, HMO), effective date, coinsurance (in and out of network), copay and deductible (annual static value only). Whether additional information is returned depends on the other Blue Plan.
If the information is not detailed enough to meet your needs, please call BlueCard Eligibility to connect to the member’s Blue Plan for additional eligibility and benefit information.
Hours of operation for other Blue Plans may vary. For Blue Plans that operate in real-time, the response time typically will be less than one minute.
If a Blue Plan operates in batch-mode or their system is not available, you will need to retrieve information from the Delayed Response Application. It may take up to 24 hours for eligibility and benefit information to be returned. The Delayed Response Application is accessed from Availity and links to the Florida Blue site. See Delayed Response for e-Transactions
for more information.
Phone – Call BlueCard Eligibility at (800) 676-2583
This line is for eligibility, benefit and precertification/referral authorization inquiries only (not claim status).
The BlueCard Eligibility line is available 24 hours a day, seven days a week. Many Blue Cross and/or Blue Shield Plans have automated self-service systems and extended hours. Please keep in mind, however, that Blue Plans are located throughout the country and may operate on different time schedules. Also, some do not have self-service capabilities. In these cases, you may need to call back at a later time.
Because the BlueCard Eligibility line routes to the member’s home plan, if you are calling regarding several members from different Blue Plans, you will need to call the BlueCard Eligibility line for each member.
Precertification and Prior Authorization
Precertification and prior authorization can be requested electronically through the Availity Health Information Network or by phone.
The out-of-area BlueCard member is responsible for obtaining precertification or prior authorization from their BCBS Plan. However, you may choose to handle this on the member’s behalf.
When the length of an inpatient hospital stay extends past the previously approved length of stay, any additional days must be approved. Failure to obtain approval for the additional days may result in claims processing delays and potential payment denials.
The member’s Blue Plan may contact you directly related to clinical information and medical records prior to treatment or for concurrent review, disease management, or case management for a specific member.
Electronic – Submit a HIPAA 278 Transaction (Health Care Services Request)
Enter the member’s ID number, including alpha prefix, as it appears on the insurance card. The alpha prefix is required to route the request to the appropriate plan.
If the member’s ID number does not have an alpha prefix, you cannot submit this request electronically. Call the applicable number on the member’s ID card.
Information returned to you depends on the information returned by the other Blue Plan. If the information returned is not available or detailed enough to meet your needs, please call BlueCard Eligibility to be connected to the member’s Blue Plan.
Note: The Health Care Services Review Inquiry transaction is not available electronically for out-of-area Blue Plan members at this time. Therefore, do not submit electronic inquiries about existing referral authorizations or inpatient precertifications.
Hours of operation for other Blue Plans may vary. For Blue Plans that operate in real-time, the response time typically will be less than one minute.
If a Blue Plan operates in batch-mode or their system is not available, you will need to retrieve information from the Delayed Response Application; it may take up to 13 days for health care services review request information to be returned. For urgent requests, call the applicable phone number on the member’s ID card. The Delayed Response Application is accessed from the Availity Health Information Network and links to the Florida Blue site. See Delayed Response for e-Transactions
for more information.
Phone – Call BlueCard Eligibility at (800) 676-2583
When you call BlueCard Eligibility (800) 676-BLUE (2583), you will be asked for the member’s alpha prefix on the ID card and routed to the member’s Blue Plan accordingly. Ask for the utilization management, precertification or authorization area.
Below is an example of how claims flow through the BlueCard Program:
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File the Claim to Florida Blue
After you provide services to a member of another Blue Plan, file the claim to Florida Blue. File claims electronically through the Availity Health Information Network, whenever possible.
If filing a paper claim, mail to:
P. O. Box 1798
Jacksonville, FL 32231-0014
Note: Other Blue Plan members are responsible for submitting non-participating provider claims to the address on the back of their member ID card.
There are two situations where you may file claims to other Blue Plans:
You Contract with a Blue Plan in a Contiguous State
Providers who are located near the border of Florida may contract with Florida Blue and a Blue Plan in an adjoining state. When you contract directly with the member’s Plan of a contiguous state, file the claim to that Plan. (For example: A Florida Panhandle physician who contracts with both Florida Blue and BCBS of Alabama and treats an Alabama member, should file the claim to BCBS of Alabama.)
Select Ancillary Providers (Lab, Durable/Home Medical Equipment and Specialty Pharmacy)
Blue Plans may contract with providers outside of their exclusive service area for services provided to local and BlueCard members within their own service area for independent clinical lab, durable/home medical equipment (DME/HME) and self-administered specialty pharmacy. Blue Plans may not contract for such services for their members that receive services outside of their service area.
Ancillary claims for independent clinical lab, DME/HME and specialty pharmacy should be filed to the Local Plan. The Local Plan is the Plan in whose service area the ancillary services are rendered.
Claim Filing Instructions:
Lab – Lab providers should file the claim to the Blue Plan in whose service area the specimen was drawn. If the lab specimen was collected in a Florida location, file to Florida Blue. The claim will be paid based on your participation status with the Local Plan.
DME/HME – DME/HME providers should file the claim to the Blue Plan in whose service area the equipment or supply was shipped to, or purchased at a retail store. If the equipment was delivered to a member in Florida, file the claim to Florida Blue. The claim will be paid based on your participation status with the Local Plan.
Specialty pharmacy – Specialty pharmacy generally includes injectables and infusion therapies. Examples of major conditions these drugs treat include, but are not limited to, cancer, HIV/AIDS, and hemophilia. Specialty pharmacies should file the claim to the Blue Plan where the ordering physician is located. If the ordering physician is in Florida, file the claim to Florida Blue. The claim will be paid based on your participation status with the Local Plan.
Once Florida Blue receives a claim, it is electronically routed, based on the alpha prefix, to the member’s Blue Plan for benefit processing and approval. The member’s Blue Plan determines benefits, coverage limitations and medical coverage guidelines. Information is returned to Florida Blue. Florida Blue then completes claim processing, issues any payment due and sends a remittance advice to the provider.
If you have not received payment for a claim, do not resubmit the claim because it will be denied as a duplicate. This also causes member confusion because multiple explanations of benefits (EOBs) are sent to the member. Please check claim status using the Availity Health Information Network
or call Florida Blue at (800) 727-2227.
Medigap Claims (Medicare Complementary/Supplemental Standard A-J policies)
The following are guidelines for the filing and processing of Medigap claims:
File the claim to your Medicare carrier for primary payment (e.g., for Medicare Part B physician services in Florida, file to First Coast Service Options).
Complete the secondary carrier information with the member’s Blue Plan information (e.g., Empire BCBS). If you do not know the member’s Blue Plan, call BlueCard Eligibility at (800) 676-BLUE (2583); when you provide the alpha prefix you will be routed to the member’s Blue Plan. Only indicate Florida Blue when Florida Blue is the member’s secondary coverage.
Not entering the member’s actual Blue Plan as the correct secondary carrier will result in claim issues. A claim crossed over in error to Florida Blue cannot be processed and you may not receive a remittance. Therefore, be sure to enter the correct Blue Plan when you submit the claim to Medicare. If your system is set-up to automatically populate Florida Blue, please change it to the correct Blue Plan.
Claim information will not be crossed over to the member’s supplement plan (the secondary payer) until after Medicare has processed the claim and released it from the Medicare payment hold. Medicare secondary claims will normally be electronically forwarded by GHI (the CMS vendor) directly to the member’s supplement Blue Plan for processing of the secondary benefits.
After receipt of the Medicare Remittance Notice, review the indicators to identify whether the claim was crossed over directly to the member’s Medicare supplement Blue Plan.
If the indicator shows the claim crossed over, Medicare has submitted the claim to the appropriate Blue Plan and the claim is in progress. You do not need to take further action. The 835 (electronic remittance) record can also carry the secondary forwarding information.
You will receive payment or processing information from the member’s supplement plan after they receive the Medicare payment. Please allow 45 days from the primary payment date for the processing of the secondary claim.
If the claim did not crossover electronically to the supplement plan, then file the claim to Florida Blue with the Medicare Remittance Notice attached. Send the claim to: Florida Blue, P.O. Box 1798, Jacksonville, FL 32231-0014. Do not send secondary claims directly to the member’s Blue Plan.
Note: If more than one claim appears on the Medicare Remittance Notice, please indicate the specific claim you are filing.
Direct inquiries on secondary claims to Florida Blue unless the member’s Blue Plan has requested specific information from you on a particular claim. Inquiries received on secondary claims by Florida Blue will be coordinated with the member’s Blue Plan for resolution.
Blue Plans around the country have made improvements to the medical records process to make it more efficient. We now are able to send and receive medical records electronically among each other. This new method significantly reduces the time it takes to transmit supporting documentation for our out-of-area claims, reduces the need to request records multiple times and eliminates lost or misrouted records.
There are times when the member’s Blue Plan requires medical records to review the claim. The following are circumstances when the provider may be requested to submit medical records for out-of-area members.
As part of the preauthorization process – If you receive requests for medical records from other Blue Plans prior to rendering services, as part of the preauthorization process, you will be instructed to submit the records directly to the member’s Plan that requested them. This is the only circumstance where you would not submit them to Florida Blue.
As part of claim review and adjudication – These requests will come from Florida Blue in the form of a letter requesting specific medical records and including instructions for submission.
BlueCard Medical Record Process for Claim Review
An initial communication, generally in the form of a letter will be sent to your office requesting the needed information.
You may receive a remittance advice indicating the claim is being denied pending receipt and review of records. Occasionally, the medical records you submit might cross in the mail with the remittance advice for the claim indicating a need for medical records. A remittance advice is not a duplicate request for medical records. If you submitted medical records previously, but received a remittance advice indicating records were still needed, contact Florida Blue to ensure your original submission has been received and processed. This will prevent duplicate records being sent unnecessarily.
If you received only a remittance advice indicating records are needed, but you did not receive a medical records request letter, contact Florida Blue to determine if the records are needed from your office.
Upon receipt of the information, the claim will be reviewed to determine the benefits.
If the records are requested following submission of the claim, forward all requested medical records to Florida Blue.
Follow the submission instructions given on the request. Fax the specific records requested and a copy of the request to (904) 361-0711. Only send BlueCard documentation to this fax line.
Include the cover letter you received with the request when submitting the medical records. This is necessary to make sure the records are routed properly once received by Florida Blue.
Submit the information to Florida Blue within ten business days to expedite processing.
Only send the information specifically requested. Frequently, complete medical records are not necessary.
Please do not proactively send medical records with the claim. Unsolicited claim attachments may cause claim payment delays.
Status inquiries should be directed to Florida Blue at (800) 727-2227.
Coordination of Benefits
If you discover the member is covered by more than one health plan, and:
- A Blue Plan is primary – When a Blue Plan is the primary payer, submit the other carrier’s name and address with the claim to Florida Blue.
- Another carrier (non-Blue Plan) is primary – When you provide services to a BlueCard member who has primary coverage with another health insurance carrier (non-Blue plan), file the claim to the primary carrier first. Once the primary carrier has completed processing, attach the primary payers’ information (payment/denial notification) to the paper claim and forward to Florida Blue. Do not submit your secondary claim to the member’s Blue Plan.
Coordination of Benefits Questionnaire
To streamline our claims processing and reduce the number of denials related to coordination of benefits, a Coordination of Benefits Questionnaire is available at www.floridablue.com
(click on Providers, Tools & Resources, then Forms) that will help you and your patients avoid potential claim issues. When you see out-of-area Blue members and you are aware that they might have other health insurance coverage, give a copy of the questionnaire to them during their visit. Ask them to complete the form and send it to the Blue Plan through which they are covered as soon as possible after leaving your office. Members will find the address on the back of their ID card or by calling the customer service numbers listed on the back of the card. Collecting coordination of benefits information from members before you file their claim eliminates the need to gather this information later, thereby reducing processing and payment delays.
You may bill the BlueCard member upfront for any deductible, copay, coinsurance or non-covered amounts. Participating physicians and providers accept the contractually agreed-upon allowance and may not balance bill the BlueCard member for the difference between their standard charge and contractual allowance.
BlueCard members with PPO coverage access the PPC network for the lowest out-of-pocket costs. The allowed amount for covered services is based on the applicable PPC fee schedule amount.
BlueCard members with Traditional, Indemnity, PPO, POS, HMO and Medigap (Medicare Complementary/Supplemental) coverage may access the Traditional/PPS/PHS network. The allowed amount for covered services is based on the applicable maximum allowable payable (MAP)/Traditional/PHS amounts. PPO members may access the Traditional/PPS/PHS network, but will usually have higher out-of-pocket costs.
If there is a reduction in payment or a denial of your claim, the remittance advice will provide an explanation as to the reason for the reduction or denial of the claim. Providers may request reconsideration of how a claim processed, paid or denied. These requests are referred to as appeals.
If the appeal requires a determination from the member’s Plan, Florida Blue will send you a letter indicating it has been sent to the member’s Plan. If you have not received a response 30 days after receipt of the letter, contact Florida Blue at (800) 727-2227.
Medicare Advantage Claims
Medicare Advantage (PPO, HMO, PFFS, POS, MSA) claims are not part of the BlueCard Program (Exception: see Medicare Advantage PPO Network Sharing Program
) and are not subject to the provisions of your participating provider agreements.
Some ID cards carry a unique logo to identify Medicare Advantage Blue Plans and indicate PPO, HMO, POS, PFFS or MSA.
Following are examples of the Medicare Advantage identifiers:
Verify eligibility by calling BlueCard Eligibility at (800) 676-BLUE (2583) and provide the member’s alpha prefix located on the ID card. You may also submit electronic eligibility requests and claims for Blue members through the Availity Health Information Network at www.availity.com
Be sure to ask if Medicare Advantage benefits apply.
If you experience difficulty obtaining eligibility information, please record the alpha prefix and report it to Florida Blue.
Submit all Medicare Advantage claims to Florida Blue. We will forward the claim to the appropriate Blue Plan.
Indicate on the claim whether you accept Medicare Assignment.
Do not bill Medicare directly for any services rendered to a Medicare Advantage member.
Based upon CMS regulations, if you are a provider who accepts Medicare assignment and renders service to Medicare Advantage members from other Blue Plans, you will be reimbursed the equivalent of the currently allowable Medicare amount (i.e., the amount you would collect if the beneficiary were enrolled in traditional Medicare) for all covered services. CMS regulations state that the Medicare allowable amount is considered payment in full.
Collect only the applicable member responsibility amounts (deductible, copayment, coinsurance, and non-covered services) at the time of service. You may not balance bill the member for the difference between your charge and the allowed amount.
Other than the applicable member cost sharing amounts, reimbursement is made directly by a Blue Plan under the provisions of the member’s benefit agreement.
Medicare Advantage PPO Network Sharing Program
Effective January 1, 2010, Florida Blue began participating in the Blue Cross and Blue Shield Association’s Medicare Advantage (MA) PPO Network Sharing Program. The MA PPO Network Sharing Program allows MA PPO members to obtain in-network benefits when traveling or living in the service areas of other MA PPO Plans as long as the member sees a participating MA PPO provider.
MA PPO shared networks are available in 18 states and one territory:
You should verify eligibility and benefits, and file claims to Florida Blue as you currently do for any out-of-area Blue Medicare Advantage member you agree to treat (see previous page).
The “MA” in a suitcase logo on the ID card indicates the member is covered under the program.
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In Florida, the MA PPO Network Sharing Program applies to providers participating in the BlueMedicare PPO network.
Participating MA PPO (BlueMedicare PPO and BlueMedicare Regional PPO) providers:
Note: Some BlueMedicare PPO and BlueMedicare Regional PPO participating facility contracts do not include MA PPO Network Sharing language. For these facilities, claims will process as out-of-network.
Members are strongly encouraged to research participating providers in the area in which they will be visiting/traveling to or permanently residing. Members can call (800) 810-BLUE or visit www.floridablue.com
, under the “Find a Doctor or Hospital” section. (If the alpha prefix is unknown, “994” can be entered online under the “Guest” tab to display MA PPO providers and facilities.)
Frequently Asked Questions
The following answers to frequently asked questions are provided to assist you and your staff in understanding how the BlueCard Program works.
What is the BlueCard Program?
BlueCard is a national program that enables members of one Blue Plan to obtain healthcare service benefits while traveling or living in another Blue Plan’s service area. The program links participating healthcare providers with the independent Blue Cross and Blue Shield Plans across the country, and in more than 200 countries and territories worldwide, through a single electronic network for claims processing and reimbursement. You may submit claims for patients from other Blue Plans, domestic and international, to your local Blue Cross and/or Blue Shield Plan. The local Blue Cross and/or Blue Shield Plan is your sole contact for education, contracting, claims payment/adjustments and problem resolution.
Questions by Topic (click on the topic)
What are the roles and responsibilities of the local Blue Cross and/or Blue Shield Plans to their providers?
Your local Blue Cross and/or Blue Shield Plan’s responsibilities include all 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 Blue Shield 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 local Blue Cross and/or Blue Shield Plan.
Conducting HIPAA standard transactions.
Training for providers on BlueCard (Plan optional)
What are the roles and responsibilities of the Member home plan to the provider?
Adjudicate claims based on member eligibility and contractual benefits.
Respond to prior authorization and pre-certification requests/inquiries.
Request medical records through the local Plan when review for medical necessity, determination of a pre-existing condition, or high cost/utilization is required.
What are the roles and responsibilities for the Provider?
Obtaining benefits and eligibility information, including covered services, copayments and deductible requirements.
Filing claims with the correct local 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 such co-pay, co-insurance or deductibles
Submitting medical records in a timely manner when requested by the local or member home Plan
How can Providers obtain member eligibility information?
Member eligibility information should be obtained by submitting a Blue Exchange Eligibility & Benefits Inquiry (HIPAA transaction 270) request through your local Blue Plan, but can also be obtained by calling 1-800-676-BLUE(2583). If prior authorization or pre-certification information is required in addition to eligibility, Providers should call 1-800-676-BLUE(2583).
It is more beneficial when submitting a HIPAA transaction 270 request to use the appropriate Service Type codes for the specific service being provided. Use of the general Service Type “30” (Health Benefit Plan Coverage) or Service Type “1” (Medical Care) may not provide enough information to address all related Inpatient, Outpatient, Emergency and Professional benefits and does not include information on Benefit Limitations and Place of Service requirements.
Verify the member’s cost sharing amount before processing payment. Co-pay, co-insurance, deductibles and accumulated benefits can be obtained from the electronic Blue Exchange Eligibility & Benefits Response (HIPAA transaction 271) to the HIPAA transaction 270. Please do not process full payment upfront.
What specific information should the Provider Obtain?
It is recommended that Providers request the most current ID card at every visit since new ID cards maybe be issued to members throughout the year. Member ID cards may include one of several logos identifying the type of coverage the member has and/or indicating the provider’s reimbursement level.
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Medicaid, State Children’s Health Insurance Programs (SCHIP) administered as a part of a state’s Medicaid program, Medicare Complementary and Supplemental products, also known as Medigap type benefits.
The provider should request specific information including eligibility, benefits, cost sharing, prior authorization/pre-certification requirements, care/utilization management requirements, and concurrent review requirements when contacting the member home Plan for benefit and eligibility information.
How should providers bill claims for out-of-area members?
Providers should bill claims for out-of-area members the same way they bill claims for their local Blue Cross and/or Blue Shield Plan members. When submitting the claim:
The member ID numbers should be reported exactly as shown on the ID card. Do not add, omit or alter any characters from the member ID number.
Indicate on the claim any payment you collected from the patient.
Only submit medical records if requested.
What should you do if you haven’t received a response to your initial claim submission?
If you have a question regarding the status of an outstanding claim, you can submit an electronic Blue Exchange Claim Status Request (HIPAA transaction 276) or contact your local Plan.
Do not send in a duplicate claim. Sending another claim or having your billing agency resubmit claims automatically slows down the claims payment process and creates confusion for the member.
How should Coordination of Benefits (COB) be handled when a member has Blue on Blue coverage? Another carrier?
In cases where Blue on Blue coverage has been identified, and the member has dual coverage with the same and/or differing Blue Plans you should consider the following:
When submitting the claim, it is essential that you enter the correct Blue Plan name as the secondary carrier. This may be different from the local Blue Plan. Check the member’s ID card for additional verification or ask them to complete the Universal Blue COB Questionnaire available on your local Plan’s website.
On the electronic HIPAA transaction 837 or paper claim, it is important in box 11D “YES” or “NO” be checked for Professional claims or form fields 50, 58-62 be completed for Institutional claims to ensure the claim will be reviewed properly by the local Blue Plan. For Professional claims if the member does not have other insurance, it is imperative that you indicate this. Leaving the box unmarked can cause the Member’s Home Plan to stop the claim to investigate for COB. By completing the information, you are helping ensure your claim will be processed more timely.
Review the EOP/EOB from the primary Blue Plan prior to submitting a claim to the secondary Blue Plan to avoid duplicate claims submission. The primary Blue Plan may have forwarded the claim to the secondary Blue Plan through BlueCard. If the secondary claim was not handled by the local Blue Plan then forward a copy of the claim to your local Blue Plan with any Other Party Liability (OPL) information included.
Carefully review the payment information from all payers involved on the remittance advice before balance billing the patient for any potential liability.
In cases where there is more than one payer and another Blue Plan or commercial insurance carrier is the primary payer, submit the other carrier’s name and address or Explanation of Benefits with the claim to your local Plan. You may also go to your local Plan’s website and download a copy of the Universal Blue COB Questionnaire that the member can complete and sign at the time of service and send it to your local Plan with the claim. Please ensure that the form is completely filled out and at a minimum, include your name and tax identification or NPI number, the policy holder’s name, group number and identification number including the three character alpha-prefix and the member’s signature. Not including the COB information with the claim may delay payment if the members home Plan investigates the claim needlessly.
If another non-Blue health plan is primary and any other Blue Plan is secondary, submit the claim to the local Plan only after receiving payment from the primary payer. Include the explanation of payment from the primary carrier with your claim submittal.
Are providers required to cooperate with the member’s Blue Plan prior authorization/pre-certification programs?
While out-of-area BlueCard members are currently responsible for obtaining prior authorization or pre-certification from their BCBS Plans, most providers choose to handle this obligation on the member’s behalf. Members may be held financially responsible if necessary approvals are not obtained and the claim is denied. The provider may have to manage debt collection in this situation.
When verifying member eligibility and benefits, providers should request information on prior authorization and pre-certification, care management/utilization management and concurrent review, as required for inpatient or outpatient services.
How can Providers obtain prior authorization/pre-certification information for out-of-area members?
Member prior authorization or pre-certification information can be obtained both electronically and telephonically.
General information on prior authorization and pre-certification information can be found on the local Blue Plan webpage under Out-of-Area Member Medical Policy and Pre-Authorization/Pre-Certification Router utilizing the three letter prefix found on the member ID card.
Providers can also contact 1-800-676-BLUE(2583) to obtain prior authorization or pre-certification information. When prior authorization or pre-certification for a specific member is handled separately from eligibility verifications at the member’s Blue Plan, your call will be routed directly to the area that handles prior authorization or pre-certification. You will choose from four options depending on the type of service for which you are calling:
If you are inquiring about both, eligibility and prior authorization or pre-certification, through 1-800-676-BLUE(2583), your eligibility inquiry will be addressed first. Then you will be transferred, as appropriate, to the prior authorization or pre-certification area.
Please note that if a prior authorization and pre-certification determination is not provided at the time of the call, the determination may be communicated to a different area (i.e. facility’s Utilization Management area) than the area that initiated the pre-certification request. Providers are encouraged to ask the member’s Blue Plan about this situation when they call in order to prevent duplicate requests.
Are facilities that are paid primarily on a DRG/case basis required to obtain approvals for length-of-stay beyond the original approval?
Whenever possible member Home Plans will consider the local Plan's payment arrangement with the facility, and if appropriate, adjust UM protocols accordingly. Many DRG contracts have stop loss provisions and revert to an alternative payment method, i.e., percent of charges, at a particular point during the course of stay. These cases need to be managed appropriately. Member Home Plans may work closely with the facility and/or local Plan to manage these potentially high-cost cases.
Claims could be subjected to length-of-stay review and potential sanctions. Providers cannot assume that if they are contacted as a DRG facility, no concurrent review will occur.
The member home plan cannot “split” payment for claims with the local plan DRG pricing. The member’s home plan must either approve or deny the entire claim. They may not pay only for specific days and deny others.
If the treatment plan changes during the inpatient stay, the original approval would not be applicable and new certification would need to be obtained. The provider can call 1-800-626-BLUE(2583) and request to speak with the Utilization Review area or submit a Blue Exchange Referral/Authorization Inquiry (HIPAA transaction 278) to the local Plan.
Providers are encouraged to inquire about concurrent review process when verifying member eligibility and benefits or when obtaining pre-certification so they are aware of what steps are needed to satisfy the member’s Home Plan concurrent review requirements. Provider benefits of the concurrent review process are:
Assist with coordinated discharge planning
Identify care management opportunities for the member
Help to reduce patient readmission
Why do member’s Blue Plans sometimes initially indicate that a service/procedure is authorized or certified under an authorization or certification process, but when the service is adjudicated, determine the service to be non-covered/denied?
These discrepancies tend to occur when there is benefit limitations that restrict; who may render the service, where they are rendered, how they are billed, or the presence of a benefit maximum. Additional factors that may affect adjudication of a claim are pre-existing conditions, additional services not included in the initial plan of treatment and/or a revised length of stay that does not match the prior authorization or pre-certification.
When obtaining prior authorization or pre-certification, please provide as much information as possible, to minimize potential claims issues. Providers are encouraged to follow-up immediately with a member’s Blue Plan to communicate any changes in treatment or setting to ensure existing authorization is modified or a new one is obtained, if needed. Failure to make the necessary notification or obtain prior authorization/pre-certification may cause a delay or denial in claims payment. Please note that prior authorization or pre-certification does not guarantee payment.
Are providers required to hold the patient harmless for penalties assessed for not following the member’s Blue Plan authorization protocols?
The out-of-area BlueCard member is responsible for obtaining pre-certification or prior authorization from his/her Blue Cross and/or Blue Shield Plan. As a result, the member is responsible for any penalty assessed for non-compliance.
Should a provider include medical records with the original claim?
Providers are not encouraged to submit unsolicited medical records or other clinical information unless requested. If medical records or other relevant information is needed to finalize the claim payment, the local Blue Cross and/or Blue Shield Plan will notify you.
If you receive requests for medical records from other Blue Plans prior to rendering services, as part of the prior authorization process, please submit them directly to the member’s Plan that requested them.
Follow the submission instructions given on the request, using the specified physical or email address or fax number. The address or fax number for medical records may be different than the address you use to submit claims.
There is a difference between reviewing a claim for medical necessity after the service has already been rendered and reviewing a prior authorization for medical appropriateness; these reviews are not the same:
Medical Necessity - validates the service is medically necessary according to their members Blue Plan medical policy.
Medically Appropriate - validates that service rendered matches the prior authorization and the dollar amounts are in-line.
When a claim has been denied for medical records and the records have been submitted to your local Plan, it is recommended that providers wait at a minimum 20 business days before submitting a follow up request for status of claim adjudication.
If you are the rendering or performing provider for a service, include the name and address of the referring or ordering provider on your original claim submission. Including this information will help ensure that if medical records are needed that they will be requested from the correct provider.
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Which Plan’s Medical Policy applies for out-of-area members?
Only a member’s Blue Plan Medical Policy applies to BlueCard claims. The member’s Blue Plan Medical Policy applies to the interpretation and determination of medical necessity, medical appropriateness, investigational/experimental care, and clinical reviews as related to administration of the member’s benefits and coverage.
Should a member’s Blue Plan ever directly contact an out-of-area provider?
The member’s Blue Plan should only contact an out-of-area provider to solicit, clarify, or confirm clinical information for the purpose of performing case management or disease management activities.
How should providers bill mother/newborn claims for out-of-area members?
Providers should bill mother/newborn services for out-of-area members the same way they bill claims for local Blue Cross and/or Blue Shield members.
Who determines the use of revenue/procedure codes?
It is the local Plans responsibility for claims coding based on the contractual agreement with the provider. When a claim contains non-standard codes, it maybe be rejected back to the provider, and the provider may be asked to resubmit with the standard code.
Who determines the appropriate use of modifiers?
The local Blue Cross and/or Blue Shield Plan is responsible for determining the appropriate use of modifiers.
How much can a contracted provider bill an out-of-area Blue member?
Providers should only bill for applicable deductibles, co-pays, co-insurance, non-covered services and/or medical management penalties specifically indicated as “Patient Responsibility” on the remittance advice for such out-of-area Blue Plan member. The provider cannot, in any event, bill the out-of-area member for the difference between billed charges and the locally negotiated allowance.
What criteria are used to determine whether the charge associated with a rendered service is a member or a contracting provider’s liability?
The criteria used to determine the provider’s liability is specific to the provider’s contract. If the provider’s contract explicitly states the provider will not be reimbursed for a specific service or based on a specific timeframe, and cannot bill the member, the provider is liable for the charge.
The criteria used to determine the member’s liability is specific to the member’s benefit contract. If the member’s benefit explicitly states the service is not covered, the member is liable for the charge.
Under what circumstances is there no payment due to the provider?
Your local Blue Plan prices claims according to the terms of its provider contracts. If a provider’s contract has a clause stating providers are liable for any costs associated with services rendered outside the provider’s scope of practice, your local Plan will indicate no payment is due to the provider. If the member’s benefit allows the service, but the provider’s contract does not, benefits will be approved, but no payment is due the provider according to his/her contract and the provider should write it off.
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How is a Provider payment determined?
Who pays the Provider?
Provider payable claims will be paid by the local Plan based on the provider’s contract and subject to the member’s benefit plan.
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All Blue Plans crossover Medicare claims for services covered under Medigap and Medicare Supplemental products. This will result in automatic claims submission of Medicare claims to the Blue secondary payer, and reduce or eliminate the need for the provider’s office or billing service to submit an additional claim to the secondary carrier.
How do I submit Medicare primary / Blue Plan secondary claims?
For members with Medicare primary coverage and Blue Plan secondary coverage, submit claims to your Medicare intermediary and/or Medicare carrier.
When submitting the claim, it is essential that you enter the correct Blue Plan name as the secondary carrier. This may be different from the local Blue Plan. Check the member’s ID card for additional verification.
Be certain to include the alpha prefix as part of the member identification number. The member’s ID card will include the alpha prefix in the first three positions. The alpha prefix is critical for confirming membership and coverage, and key to facilitating prompt payments.
When should I expect to receive payment for Medicare Crossover claims?
The claims you submit to the Medicare intermediary will be crossed over to the Blue Plan after they have been processed by the Medicare intermediary. This process may take up to 14 business days. This means that the Medicare intermediary will be releasing the claim to the Blue Plan for processing about the same time you receive the Medicare remittance advice. As a result, it may take an additional 14-30 business days for you to receive payment from the Blue Plan.
To determine if your claim has crossed over, review the Remittance Advice (RA) you receive from Medicare. The RA will show a crossover indicator that Medicare has submitted the claim to the appropriate Blue Plan and the claim is in progress. If there is no crossover indicator on the RA, providers should submit the claim along with the Medicare RA to the local Plan.
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How do I handle Medicare Advantage (MA) claims?
For Medicare Advantage, submit claims to the local Blue Plan. Do not bill Medicare directly for any services rendered to a Medicare Advantage member.
Ask for the member ID card. Members will not have a standard Medicare card; instead, Medicare Advantage members have distinctive product logos on their medical ID card to help you recognize them. All logos have the term “Medicare Advantage” in the design.
Verify eligibility by contacting 1-800-676-BLUE(2583) and providing the alpha prefix. Be sure to ask if Medicare Advantage benefits apply.
Please review the remittance notice concerning Medicare Advantage plan payment, member’s payment responsibility and balance billing limitations.
What does Medicare Advantage PPO Network Sharing mean?
If you are a contracted MA PPO provider with the local plan and you see MA PPO members from other Blue Plans, these members will be extended the same contractual access to care and will be reimbursed in accordance with your negotiated rate with your local Blue Plan contract. These members will receive in-network benefits in accordance with their member contract.
NOTE: If you are not a contracted MA PPO provider with your local Plan and you provide services for any Blue MA members, you will receive the Medicare allowed amount for covered services. For Urgent or Emergency care, you will be reimbursed at the member’s in-network benefit level. Other services will be reimbursed at the out-of-network benefit level.
Ancillary Claims Filing
Where should I file Ancillary Claims?
Ancillary providers include Independent Clinical Laboratory, Durable/Home Medical Equipment and Supplies and Specialty Pharmacy providers. File claims for these providers as follows:
*If you contract with more than one Plan in a state for the same product type (i.e., PPO or Traditional), you may file the claim with either Plan.
For information that applies to ancillary providers with participation agreements that designate the ACFS as the contractual fee schedule, click on the link below.
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What are the rules for filing claims for Contiguous Counties?
Claims filing rules for contiguous area providers are based on the permitted terms of the provider contact, which may include:
Provider Location (i.e. which Plan service area is the providers office located)
Provider contract with the two contiguous counties (i.e. is the provider contracted with only one or both service areas).
The member’s Home plan and where the member works and resides (i.e. is the member’s Home Plan with one of the contiguous counties plans).
The location of where the services were received (i.e. does the member work and reside in one contiguous county and see a provider in another contiguous county).
NOTE: Contiguous Counties guidelines do not apply to Ancillary Claims Filing. Ancillary claims must be filed to the local Plan based on the type of ancillary service provided.
What are the rules for filing claims in Overlapping Service Areas?
Submission of claims in Overlapping Service Areas is dependent on what Plan(s) the Provider contracts with in that state, the type of contract the Provider has (ex. PPO, Traditional) and the type of contract the member has with their Home Plan.
If you contract with all local Blue Plans in your state for the same product type (i.e., PPO or Traditional), you may file an out-of-area Blue Plan member’s claim with either Plan.
If you have a PPO contract with one Blue Plan, but a Traditional contract with another Blue Plan, file the out-of-area Blue Plan member’s claim by product type.
If you contract with one Plan but not the other, file all out-of-area claims with your contracted Plan.
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What is an Administrative Services Only (ASO) account?
ASO accounts are self-funded, where the local plan administers claims on behalf of the account, but does not fully underwrite the claims. ASO accounts may have benefit or claims processing requirements that may differ from non-ASO accounts. There may be specific requirements that affect; medical benefits, submission of medical records, Coordination of Benefits or timely filing limitations.
The local plan receives and prices all local claims, handles all interactions with providers, with the exception of Utilization Management interactions, and makes payment to the local provider. As with any member benefit contract be sure to verify member eligibility and benefits when rendering service.
How should clearinghouses be notified of changes in claims processing guidelines or policy?
It is the Providers responsibility to ensure any changes to claims processing guidelines or policy is communicated to any billing service, clearinghouse or payer the provider has a vendor arrangement with to process your claims. Failure to do so in a timely manner may result in delays or denials of payment due to incorrect claims submission.