A number of clients ask us about Blue Card PPO and how it works. Blue Card PPO is typically attached to our clients policies who are enrolled on an IBC Personal Choice PPO or National Network PPO or a Horizon Blue Cross plan with National Access. You can tell if you have this on your plan if your card has the PPO Traveling Briefcase logo:
It’s important to note that members who have a Keystone HMO, Amerihealth or Horizon HMO or local EPO do NOT have Blue Card PPO.
How Does the BlueCard Program Work?
BlueCard® PPO Medical Plan
The BlueCard Preferred Provider Organization (PPO) medical plan gives you the freedom to select in-network or out-of-network health care providers to administer covered health care services.
When you use a network doctor or hospital, there is very little to pay out-of-pocket. Additional advantages are no claim forms and no balance bills.
- In the Philadelphia region¹ you can select providers from the Personal Choice® Provider Network
- Outside of the Philadelphia region¹ you can select from the BlueCard® PPO Provider Network
You can use a doctor or hospital that is not in the Personal Choice or BlueCard PPO Networks, however, you’ll pay more for these services and will have to submit a claim for reimbursement.
PPO Plan Features:
- no need to select a primary care physician to coordinate your care;
- visit specialists directly: no referrals are required;
- wellness programs, including fitness reimbursement and discounts on alternative health care services, at no additional cost;
- preventive care for children and adults;
- enjoy in-network coverage anywhere in the United States when you use providers that participate in the Personal Choice or BlueCard PPO networks;
- worldwide coverage and recognition of the Blue Cross® symbol.
Blue Card PPO information for Providers
How to Identify BlueCard Members
When members from other Blue Cross and Blue Shield Plans arrive at your office or facility be sure to ask them for their current Blue Plan membership identification card. The main identifiers for BlueCard members are the alpha prefix, a blank suitcase logo, and, for eligible PPO members, the “PPO in a suitcase” logo.
The three-character alpha prefix at the beginning of the member’s identification number is the key element used to identify and correctly route out-of-area claims. The alpha prefix identifies the Blue Cross Blue Shield Plan or national account to which the member belongs. It is critical for confirming a patient’s membership and coverage.
There are two types of alpha prefixes: Plan-specific and account-specific.
- Plan-specific alpha prefixes are assigned to every Plan and start with X, Y, Z or Q. The first two positions indicate the Plan to which the member belongs while the third position identifies the product in which the member is enrolled.
First character: X, Y, Z or Q
Second character: A-Z
Third character: A-Z
- Identification cards with no alpha prefix: Some identification cards may not have an alpha prefix. This may indicate that the claims are handled outside the BlueCard Program. Please look for instructions or a telephone number on the back of the member’s ID card for how to file these claims. If that information is not available, call The Local Blue Cross and Blue Shield.Account-specific prefixes are assigned to centrally processed national accounts. National accounts are employer groups that have offices or branches in more than one area, but offer uniform benefits coverage to all of their employees. Account-specific alpha prefixes start with letters other than X, Y, Z or Q. Typically, a national account alpha prefix will relate to the name of the group. All three positions are used to identify the national account.
It is very important to capture all ID card data at the time of service. This is critical for verifying membership and coverage. We suggest that you make copies of the front and back of the ID card and pass this key information on to your billing staff. Do not make up alpha prefixes.
If you are not sure about your participation status (traditional, PPO, POS, or HMO), call The Local Blue Cross and Blue Shield.
Blank Suitcase Logo
A blank suitcase logo on a member’s ID card means that the patient has Blue Cross Blue Shield traditional, POS, or HMO benefits delivered through the BlueCard Program.
“PPO in a Suitcase” Logo
You’ll immediately recognize BlueCard PPO members by the special “PPO in a suitcase” logo on their membership card. BlueCard PPO members are Blue Cross and Blue Shield members whose PPO benefits are delivered through the BlueCard Program. It is important to remember that not all PPO members are BlueCard PPO members, only those whose membership cards carry this logo. BlueCard PPO members traveling or living outside of their Blue Plan’s area receive the PPO level of benefits when they obtain services from designated BlueCard PPO providers.
How to Identify BlueCard Managed Care/POS Members
The BlueCard Managed Care/POS program is for members who reside outside their Blue Plan’s service area. However, unlike other BlueCard programs, BlueCard Managed Care/POS members are enrolled in The Local Blue Cross and Blue Shield network and primary care physician (PCP) panels. You can recognize BlueCard Managed Care/POS members who are enrolled The Local Blue Cross and Blue Shield’s network through the member ID card as you do for all other BlueCard members. The ID cards will include (1) a local network identifier and (2) the three-character alpha prefix preceding the member’s ID number. The POS ID card also includes the blank suitcase logo.
How to Identify International Members
Occasionally, you may see identification cards from foreign Blue Cross and Blue Shield Plan members. These ID cards will also contain three-character alpha prefixes. Please treat these members the same as domestic Blue Cross and Blue Shield Plan members.
How to Verify Membership and Coverage
Once you’ve identified the alpha prefix, call BlueCard Eligibility to verify the patient’s eligibility and coverage.
|1. Have the member’s ID card ready when calling.|
|2. Dial 1.800.676.BLUE.|
Operators are available to assist you weekdays during regular business hours (7am – 10pm EST). They will ask for the alpha prefix shown on the patient’s ID card and will connect you directly to the appropriate membership and coverage unit at the member’s Blue Cross Blue Shield Plan. If you call after hours, you will get a recorded message stating the business hours.
Keep in mind BCBS Plans are located throughout the country and may operate on a different time schedule than The Local Blue Cross and Blue Shield. It is possible you will be transferred to a voice response system linked to customer enrollment and benefits or you may need to call back at a later time.
How to Obtain Utilization Review
You should remind patients from other Blue Plans that they are responsible for obtaining precertification/preauthorization for their services from their Blue Cross and Blue Shield Plan. You may also choose to contact the member’s Plan on behalf of the member. If you choose to do so, you can ask to be transferred to the utilization review area when you call BlueCard Eligibility (1.800.676.BLUE (2583) for membership and coverage information.
Where and How to Submit BlueCard® Program Claims
You should always submit BlueCard claims to The Local Blue Cross and Blue Shield. Be sure to include the member’s complete identification number when you submit the claim. The complete identification number includes the three-character alpha prefix. Do not make up alpha prefixes. Incorrect or missing alpha prefixes and member identification numbers delay claims processing.
Once The Local Blue Cross and Blue Shield receives a claim, it will electronically route the claim to the member’s Blue Cross and Blue Shield Plan. The member’s Plan then processes the claim and approves payment, The Local Blue Cross and Blue Shield will pay you.
If you are a non-PPO (traditional) provider and are presented with an identification card with the “PPO in a suitcase” logo on it, you should still accept the card and file with your local Blue Cross and Blue Shield Plan. You will still be given the appropriate traditional pricing.
The claim submission process for international Blue Cross and Blue Shield Plan members is the same as for domestic Blue Cross and Blue Shield Plan members. You should submit the claim directly to The Local Blue Cross and Blue Shield.
Indirect, Support or Remote Providers
If you are a health care provider that offers products, materials, informational reports and remote analyses or services, and are not present in the same physical location as a patient, you are considered an indirect, support, or remote provider. Examples include, but are not limited to, prosthesis manufacturers, durable medical equipment suppliers, independent or chain laboratories, or telemedicine providers.
If you are an indirect provider for members from multiple Blue Plans, follow these claim filing rules:
|If you have a contract with the member’s Plan, file with that Plan.|
|If you normally send claims to the direct provider of care, follow normal procedures.|
|If you do not normally send claims to the direct provider of care and you do not have a contract with the member’s Plan, file with your local Blue Cross and Blue Shield Plan.|
Exceptions to BlueCard Claims Submissions
Occasionally, exceptions may arise in which The Local Blue Cross and Blue Shield will require you to file the claim directly with the member’s Blue Plan. Here are some of those exceptions:
|You contract with the member’s Blue Plan (for example, in contiguous county or overlapping service area situations).|
|The ID card does not include an alpha prefix.|
|A claim is returned to you from The Local Blue Cross and Blue Shield because no alpha prefix was included on the original claim that was submitted.|
In some cases, The Local Blue Cross and Blue Shield will request that you file the claim directly with the member’s Blue Plan. For instance, there may be a temporary processing issue at The Local Blue Cross and Blue Shield, the member’s Blue Plan or both that prevents completion of the claim through the BlueCard Program.
When in doubt, please send the claim to The Local Blue Cross and Blue Shield and we will handle the claim for you.
Claims for Accounts Exempt from the BlueCard Program
When a member belongs to an account that is exempt from the BlueCard Program, The Local Blue Cross and Blue Shield, will electronically forward your claims to the member’s Blue Plan. That means you will no longer need to send paper claims directly to the member’s Blue Plan. Instead, you will submit these claims to The Local Blue Cross and Blue Shield. However, you will continue to submit Medicare supplemental (Medigap) and other COB claims under your current process (see below).
How the Electronic Process Works
You will submit these claims with alpha prefixes exempt from BlueCard directly to The Local Blue Cross and Blue Shield, which will forward the claims to the member’s Plan for you.
|It is important for you to correctly capture on the claim the member’s complete identification number, including the three-character alpha prefix at the beginning. If you don’t include this information, The Local Blue Cross and Blue Shield may return the claim to you and this will delay claims resolution and your payment.|
|It is also important for you to call BlueCard Eligibility at 1.800.676.BLUE to verify the member’s eligibility and coverage.|
If the member’s claim is exempt from the BlueCard Program, The Local Blue Cross and Blue Shield will either advise you to file the claim directly to the member’s home plan or inform you that the claim is being forwarded to the member’s Plan.
In most cases, the member’s Blue Plan will contact you for additional information. For example, if the member’s Plan can’t identify the member, the member’s Blue Plan may return the claim to you just as it would currently with a paper claim. If this happens, you will need to check and verify the billing information and resubmit the claim with additional/corrected information to The Local Blue Cross and Blue Shield.
The member’s Blue Plan will send you a detailed EOB/payment advice with your payment or will send a notice of denial. If you have already been paid or you do not contract with The Local Blue Cross and Blue Shield, the member’s Blue Plan may pay the member.
Coordination of Benefits (COB) Claims
Coordination of benefits (COB) refers to how we make sure people receive full benefits and prevent double payment for services when a member has coverage from two or more sources. The member’s contract language gives the order for which entity has primary responsibility for payment and which entity has secondary responsibility for payment.
Medicare Supplemental (Medigap) Claims
For Medicare supplemental claims, always file with the Medicare contractor first. Always include the complete Health Insurance Claim Number (HICN); the patient’s complete Blue Cross Blue Shield Plan identification number, including the three-character alpha prefix; and the Blue Cross Blue Shield Plan name as it appears on the patient’s ID card, for supplemental insurance. This will ensure cross-over claims are forwarded appropriately.
Do not file with The Local Blue Cross and Blue Shield and Medicare simultaneously. Wait until you receive the Explanation of Medical Benefits (EOMB) or payment advice from Medicare. After you receive the Medicare payment advice/EOMB, determine if the claim was automatically crossed over to the supplemental insurer.
Cross-over Claims: If the claim was crossed over, the payment advice/EOMB should typically have Remark Code MA 18 printed on it, which states, “The claim information is also being forwarded to the patient’s supplemental insurer. Send any questions regarding supplemental benefits to them.” The code and message may differ if the contractor does not use the ANSI X12 835 payment advice. If the claim was crossed over, do not file for the Medicare supplemental benefits. The Medicare supplemental insurer will automatically pay you if you accepted Medicare assignment. Otherwise, the member will be paid and you will need to bill the member.
Claim Not Crossed Over: If the payment advice/EOMB does not indicate the claim was crossed over and you accepted Medicare assignment, file the claim as you do today. The Local Blue Cross and Blue Shield or the member’s BCBS Plan will pay you the Medicare supplemental benefits. If you did not accept assignment, the member will be paid and you will need to bill the member.
Payment for BlueCard® Claims
Payment to you will be according to your contract with The Local Blue Cross and Blue Shield and is also dependent up the benefits of the member.
If you haven’t received payment, do not resubmit the claim. If you do, The Local Blue Cross and Blue Shield will have to deny the claim as a duplicate. You will also confuse the member because he or she will receive another EOB and may unnecessarily call customer service. Please understand that timing for claims processing varies at each Blue Cross Blue Shield Plan. The Local Blue Cross and Blue Shield standard time for claims processing is usually within 30 days.
The next time you don’t receive your payment or a response regarding your payment, please call The Local’s dedicated BlueCard Customer Service Unit.
In some cases, a member’s Blue Cross and Blue Shield Plan may suspend a claim because medical review or additional information is necessary. When resolution of claim suspensions requires additional information from you, The Local Blue Cross and Blue Shield may either ask you for the information or give the member’s Plan permission to contact you directly.