BlueCard^® connection: Answers to recent questions

BlueCard Connection is part of an ongoing series dedicated to helping improve your experience with the BlueCard program.

This month we’re discussing how to appropriately report the following:

• Claims for private rooms when your hospital no longer offers a semi-private room option
• The GY modifier on a professional claim when you are reporting a Medicare-excluded service

Reporting claims for private rooms when no semi-private rooms are available
The same reporting requirement that you are required to follow for Blue Cross Blue Shield of Michigan members applies to claims you bill for BlueCard members.

When reporting a private room because a semi-private room is no longer available at your facility, please report:

• Condition code 38 (form locators 18-26) on the UB claim form
• In the 837 report in the 2300 Loop, HI Segment, a BG Qualifier
• Value code 02 (form locators 18-26) with your private-room rate
• In the 837 report in the 2300 Loop, HI Segment, a BE Qualifier

Reimbursement for the room is based on your contracted diagnosis-related group, or DRG, rate for semi-private rooms or your per diem room rate for all claims, including BlueCard. But reporting the private room correctly may prevent a claim rejection from the member’s home plan for the private room.

Do not report the difference between the private-room rate and the semi-private room rate as a noncovered charge on the claim (form locator 48 or its electronic equivalent). Your BCBSM-contracted reimbursement for the semi-private admission should be considered payment in full and not the member’s responsibility.

Reporting the GY modifier for professional services not covered by Medicare
Professional providers do not have to submit statutorily excluded services to Medicare for consideration.

Instead, they can follow these steps:

• Submit the professional claim for a BlueCard member as you would for a Michigan member. 
• Report the GY modifier on each claim line to advise the plan that the reported service is excluded by Medicare and was not billed. The claim will be forwarded to the member’s home plan with the GY modifier as you reported. In the 837 report in the 2300 Loop, SV101-3 – SV101 – 6.

The decision to pay or reject the claim will be made by the member’s home plan based on the member’s contracted benefits. The member’s home plan does not require a Medicare Explanation of Member’s Benefit Statement. If you report your claim correctly and receive an incorrect rejection requesting a copy of an EOMB, please contact our Provider Inquiry department.

If you submit both covered and noncovered services to Medicare on a combined claim, and the home plan receives the claim as a Medicare crossover, the home plan may deny the crossover claim. The plan may also instruct the provider to split the reporting of the covered and noncovered services on two separate claims.