Here’s how to file ancillary claims

In November 2013, we updated you on the Blue Cross and Blue Shield Association’s mandate for reporting ancillary laboratory and DME claims. We continue to get inquiries on how these claims should be reported and whom you should contact when you have questions. The information below should assist you.

In general, health care providers should file claims for services rendered to Blue Cross Blue Shield members with the member’s local Blue plan. However, some special rules apply when filing ancillary claims for laboratory, durable medical equipment and specialty pharmacy services.

The Blue Cross and Blue Shield Association has mandated that BlueCard^® ancillary claims for laboratory, DME and specialty pharmacy services must be filed in the state where the referring provider resides. Here are additional details.

Independent clinical laboratory services — Claims for laboratory services must be billed to the Blue plan in the state where the referring provider resides.

Durable medical equipment — Regardless of where the order for the equipment was originated, the claim must be reported to the plan where the equipment was shipped to (use location 12-home) or purchased at (use location 11-office), if bought at a retail store.

Specialty pharmacy — This is a pharmacy that provides non-routine, biological therapeutics, ordered by a health care professional, and covered as a medical benefit, as defined by the plan’s specialty pharmacy formulary, or drug list. A specialty pharmacy generally offers injectables and infusion therapies, high-cost therapies and therapies requiring complex care. Specialty pharmacy claims should be filed with the plan where the ordering physician is located.

You can find a list of plan addresses on web-DENIS by following these steps:

• Click on BCBSM Provider Publications and Resources.
• Click on Newsletters and Resources.
• Click on Other BCBS Plan Claim Addresses under Operations and Training.

When there are multiple Blue plans within a state
Some providers may not be sure where to submit ancillary claims when there are multiple plans operating within a state, such as in New York, Pennsylvania and California. In these instances, providers should file the claim with the plan where the referring provider is registered. If you’re unsure of where the referring provider is registered, contact our Provider Inquiry department, which can help you determine where to file the claim.

When a claim is rejected
If you’re the billing provider and you receive a claim rejection advising you to report the claim to your home plan — and you believe you had filed the claim correctly with the appropriate plan — contact Provider Inquiry to assist you. If you have any further concerns, please contact your provider consultant.

To read more about BlueCard, see this month’s installment in our BlueCard series, also in this issue.