BlueCard^® connection: Data analysis supports need to verify eligibility and benefits

As part of our ongoing series on the BlueCard program, this month we want to share the results of our BlueCard claims data analysis.

The BlueCard Provider Advocate department recently completed data analysis on BlueCard claims we processed in January and June 2015. The top five rejections for both professional and facility claims related to eligibility and benefits. You can avoid getting these rejections by verifying the out-of-state member’s coverage before rendering the service.

There are several ways to verify benefits and whether your member has active coverage. You can also determine if an authorization is required for the service or treatment you’re going to provide.

Here are your options for verifying the information:

• Call the BlueCard line toll-free at 1-866-676-2583. The member’s three-letter alpha prefix will route you to his or her home plan. It’s also important to know that:
• Prompt 1 will provide you with eligibility and benefit information.
• Prompt 2 will allow you to verify and execute a required authorization.
• After completing the automated response for benefits and eligibility, most plans offer you an option to speak with a representative. The option to speak with a representative is generally only available after you have completed the automated process.

• BlueExchange on web-DENIS enables you to obtain eligibility and benefit information for out-of-state Blue Cross and Blue Shield patients directly from their home plans. Follow these steps to receive the information you need:
  • Complete all of the fields marked with an asterisk.
  • Enter the information exactly as it appears on the member’s ID card, including the correct spelling of his or her name and accurate birthdates. 
  • If the member is not the subscriber of the plan, you’ll need to provide information for both people.
  Note: The amount of information you receive from each plan — and how the information is displayed — will be different based on the individual Blue plan.

• Check the medical policy or pre-authorization router for out-of-state plans’ medical policies and authorization requirements. The member’s three-letter alpha prefix will route you to the website of the member’s home plan. A link to the router is available on Provider Secured Services, web-DENIS and in the BlueCard chapter of every online provider manual. Clinicians who don’t have a Blue Cross Blue Shield of Michigan web-DENIS ID may access the same information via a link to the router under the Quick Links tab on Provider Secured Services at bcbsm.com.

Benefits and eligibility can also be requested via the American National Standards Institute — or ANSI — ASCX12N270/271 (005010X279A1) electronic transactions. Information on these transactions can be found on the Blue Cross website here. The Health Care Eligibility Benefit Inquiry and Response Technical Report Type 3, or TR3, is standard for eligibility transactions.

As we prepare for our 2016 initiatives, discuss with your consultant what we can do to improve your BlueCard experience. Topics and suggestions will be communicated in future Record articles.

For more information on the BlueCard program, including links and articles on online tools, reference the BlueCard chapter of 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.