BlueCard^® connection: answer to a recent question

As part of our ongoing series on the BlueCard program, here’s the answer to a question we recently received.

When a BlueCard claim rejects, is that a Blue Cross Blue Shield of Michigan decision or is the rejection I see on the claim coming from the out-of-state plan?

A BlueCard claim can be rejected either by Blue Cross Blue Shield of Michigan or by the out-of-state plan, depending on the situation. Blue Cross may reject the claim before it is sent electronically to the plan for processing if the claim isn’t billed according to our reporting requirements, or the claim has inaccurate or missing information. All BlueCard claims should be reported as you would report a claim for a Michigan member. The claim is then electronically sent to the out-of-state plan. If the BlueCard claim is approved by the out-of-state plan, the claim will be reimbursed according to your contracted Blue Cross Blue Shield of Michigan rate less any member contracted cost sharing.

Examples of why we may reject your Bluecard claim before we electronically transmit it to the member’s home plan include:

• Claims with any missing or inappropriate coding based on Blue Cross Blue Shield of Michigan reporting requirements
• Reporting a service that’s not billable based on your provider contract
• Reporting a three-letter alpha prefix with the member’s ID that’s not active and therefore the BlueCard plan could not be identified

Out-of-state plans may reject your BlueCard claim if:

• The member’s eligibility cannot be confirmed or isn’t active for the date of service reported
• The service reported isn’t a contracted benefit per the member’s contract
• The information on the claim doesn’t support medical necessity or doesn’t meet the out-of-state plan’s medical or benefit policy
• A required authorization or pre-service review wasn’t obtained according to the plan’s policy
• The member’s home plan requires medical records to determine the plan’s benefit or medical policy, or the member’s contracted benefits for the services reported
• Benefits may have been exhausted for the service you reported per the member’s contract

If you need additional information on the rejected BlueCard claim, contact our Provider Inquiry department for assistance. For additional information on the BlueCard program, refer to the BlueCard chapter in the online provider manuals.

If you’re experiencing issues with the information provided in the BlueCard chapter or any of the online tools — or if you’d like more information on a particular topic — contact your provider consultant. If you’d like to suggest a topic to be covered in a future issue of The Record, send an email to ProvComm@bcbsm.com and put “BlueCard series” in the subject line.