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Reminder: BCBSNC upfront member collection policy

Blue Options (HSASM and HRASM), non-copayment products

Collecting the patient's share of the bill has become increasingly important in recent years as more cost has shifted to members. For Blue Options HSASM and Blue Options HRASM non-copayment products, many patients with high deductibles also pay a percentage of the remaining bill. Blue Cross and Blue Shield of North Carolina (BCBSNC) collection policy allows us to work with providers to reduce the administrative expenses that can add to the total cost of health care, while protecting our members when presented with large and sometimes unexpected medical bills.

For services provided by you to a member enrolled in one of the BCBSNC Blue Options deductible and coinsurance-only products (products without copayments), as a BCBSNC participating provider you agree to:

  • Establish and maintain a policy and process for collection of estimated patient financial responsibility, and assist the member with payment plan options in the event that a member cannot pay the complete estimated patient responsibility in advance of receiving service. If a member is unable to pay at the time of service, a provider should not refuse to provide necessary treatment to the member.
  • Inform the member in advance that the amount being collected is an estimated amount.
  • Request a payment amount according to your negotiated BCBSNC network fee schedule, which is effective at the time of service, and appropriate to that member's particular coverage type.
  • Provide your charge collection staff access to the current fee allowances (BCBSNC allowable reimbursements for billed charges), a listing of specific services to be delivered to a member that includes CPT codes and applicable allowances for those CPT codes, accompanied with the codes/charges to be billed to BCBSNC for the member's incident of care.
  • Calculate the member's out-of-pocket costs based on the lesser of the allowable reimbursement amount or billed charges, taking into account the member's benefit year-to-date deductible or coinsurance benefit status (amount met).
  • Collect only an amount determined to be accurate with reasonable certainty through validation of the member's estimated liability, using tools such as Blue eSM and/or RealMed.
  • Utilize and take into consideration C-3 bundling logic and BCBSNC policies addressing; medical, payment and evidence based guidelines before requesting payment from a member.
  • Final determination of what the member owes will be based on the claim that is submitted to BCBSNC, and only amounts reflected on the final EOP (Explanation of Payment) from BCBSNC as member responsibility.
  • Any applicable refund for overpayment owed to a member will be issued as soon as identified, but no later than 45 days after payment is received for the service.

BCBSNC policy for all other products prohibits participating providers from requiring upfront payment from a member until the EOP is received from BCBSNC, which will include the correct amount to be collected. Additionally, providers are requested that as a courtesy to members enrolled in HRA and HSA products, to wait until receipt of BCBSNC's EOP for services provided, when services are provided during the first quarter of a new year, as many employer groups make their annual contributions to employees' health reimbursement and savings accounts during this period.

BCBSNC members with non-copayment plans should expect to pay their applicable portion at the time a service is rendered. When deductible and/or coinsurance apply, providers should always follow the BCBSNC guidelines outlined in the Blue BookSM Provider Manual for upfront collection of member liability. Special guidelines for emergency room, urgent care, hospital and freestanding clinic are also addressed in the provider manual.