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Revised: BCBSNC Requirements for Filing Ancillary Claims

PLEASE NOTE:  This is an updated version of the article originally published in June 2012 and clarifies that claims payments for nonparticipating ancillary providers will be issued to either 1) members enrolled in BCBSNC’s commercial products, or 2) to providers who participate in BCBSNC’s Medicare Advantage plans. This revised article also reiterates that independent clinical labs are required to file claims to the Blue Plan in the state where the referring provider is located, as determined by the ZIP code for the provider’s NPI number. 

Effective October 14, 2012, Blue Cross and Blue Shield of North Carolina (BCBSNC) made changes to its claims processing system, which automated claim filing requirements for ancillary providers and resulted in some changes regarding where claims should be submitted and how they are processed.  The revised claims filing guidelines for ancillary providers included: 

  • Services performed by an independent clinical laboratory (lab) should be filed to the Blue Plan in the state where the referring provider is located, as determined by the ZIP code for the provider’s NPI number, regardless of the provider’s contract status with that Plan.  This is a clarification of an existing requirement.  All participating providers who have not complied with this requirement to-date should immediately begin doing so in order for claims to process correctly.

Note:  Independent clinical laboratory services are provided by any nonhospital-based laboratory and generally include, but are not limited to, blood tests, urine analysis, etc. To be an in-network provider, an independent clinical laboratory provider should participate with the Blue Plan in the state in which the specimen was drawn.  The location of where the specimen was drawn is determined by the physical location of the referring provider (see box 17B on the HCFA 1500). 

  • Durable/home medical equipment and supplies (DME) should be filed to the Blue Plan in the state where the equipment was shipped to, or where the store is located, if the item was purchased at a retail location.                                      
  • Specialty pharmacy claims should be filed to the Blue Plan based on the location of the ordering physician. 

Remote Provider Type

Where to File

Example

Remote Provider Contract With BCBSFL (for example)

Independent Clinical Laboratory (lab)

The Plan in the state where the referring provider is located, regardless of the provider’s contract status with that Plan   

Example 1: BCBSNC member has blood drawn in a lab or office setting located in Florida per referral by a Florida provider. 

File to:  BCBSFL

 

Example 2: BCBSNC member has blood drawn in a lab or office setting located in Florida per referral by a North Carolina provider. 

File to:  BCBSNC

Yes – Claim is processed as participating

No – Claim is processed as nonparticipating*

Durable Medical Equipment (DME)

The Plan in the service area  where the equipment was shipped to or purchased at a retail store

BCBSNC member purchases DME, and DME is shipped from the provider to Florida address.   

File to:  BCBSFL

Yes – Claim is processed as participating 

No – Claim is processed as nonparticipating*

Specialty Pharmacy

The Plan in the service area where the ordering physician is located

BCBSNC member receives medication ordered by a Florida provider. 

File to:  BCBSFL

Yes – Claim is processed as participating

No – Claim is processed as nonparticipating*

 * Please note that when a nonparticipating provider’s claim for a BCBSNC commercial member is processed that any payment will be made to the member.  When a nonparticipating provider’s claim for a Medicare Advantage member is processed, payment for that claim will be made to the provider.

 Items to Remember

  • The ancillary claim filing rules apply regardless of the provider’s contracting status with the Blue Plan where the claim is filed.
  • Providers are encouraged to verify member eligibility and benefits electronically using Blue eSM.   Providers should call 1-800-676-BLUE (2583) or the number on the member’s ID card prior to providing any ancillary service.
  • Providers who use outside vendors for services (example: sending blood specimen for special analysis that cannot be done by the lab where the specimen was drawn) should use in-network ancillary providers for these services, in order to reduce the possibly of additional member liability for out-of-network services.  For a list of specialty pharmacies and participating DME providers, please use the Find a Doctor search tool at www.bcbsnc.com, or contact the Provider Blue LineSM at 1.800.214.4844 to verify participating laboratories.
  • Members are financially liable for ancillary services not covered under their benefit plan.  It is the provider’s responsibility to request payment directly from the member for noncovered services.   

These ancillary claims filing requirements apply to all BCBSNC commercial lines of business, including the State Health Plan and our Medicare Advantage products (Blue Medicare HMO Blue Medicare PPO). This requirement does not apply to the Federal Employee Program or to our Medicare Supplemental products. 

If you have any questions, please contact the Provider Blue LineSM at 1.800.214.4844.