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David McGill Blogger

Blue Card Changes

Posted by David McGill | September 28, 2012

“The only constant is change”– Heraclitus a 500BC, Greek philosopher

The Blue Cross Blue Shield Association has notified the 39 independent Blue Plans of a change to the BlueCard® program that requires ancillary claims to be filed to their local plans. This ruling impacts independent clinical labs, DME/HME and specialty pharmacy providers. Many of the Blue Plans have already implemented this new procedure and Anthem has notified their contracted providers this process will become effective October 14, 2012. Anthem is the Blue Cross Blue Shield plan is 14 states, including California.

What Does This Mean?

First, this new ruling will impact billing of DME delivered to patients at home.

Second, the BlueCard® program historically defined the “local plan” as the service area where the provider was located. The revised ruling now defines the “local plan” as the service area where the equipment is delivered. An example illustrates the impact of this change:

a provider with a distribution center in Arizona provides a TENS unit to a patient residing in Iowa. The provider is contracted with the Blue Plan in Arizona. Under the new ruling, the provider must submit the claim to the Blue Plan in Iowa, regardless of whether it has a contract or not. Importantly, this means the claim may be processed at the out-of-network benefit level and financially impact both the patient and provider.

Third, and complicating matters is the fact that many of the Blue plans are not contracting with new, out-of-state providers, making it impossible for those individuals to get reimbursed at the in-network benefit level.

And one final twist: many Blue Plans pay out-of-network benefits directly to the patient. So, looking at the above example, if the provider is not contracted with the Blue plan in Iowa, the reimbursement will go to the patient, and the provider will be forced to pursue the patient directly for the entire payment. The effects of this ruling are not yet entirely clear. There are questions about what is included in the DME category. Does this include only the “E” HCPCS codes or does it also include orthotics billed under the “L” HCPCS codes? The various Blue plans have not yet been able to answer this question consistently.

Also, in order to determine location, the Blue Plans are now requiring the Place of Service field (Field 24B on the CMS 1500 Health Insurance Claim Form or - Loop 2300, CLM05-1 on the 837 Professional Electronic Submissions) on the claim to be completed with the patient’s address. Yet, there is no clarity as to how the claim will be processed if this field is left blank.

What Should You Do?

Until the BCBS Association provides further clarification, bill any DME services to the place of service Blue Plan. If you are not contracted with that plan, have a financial responsibility discussion with the patient before delivering anything. You may also wish to educate patients about how this restricts their care and how it affects them financially so that they can make an informed decision about whether to file a complaint with their plan. Finally, review your current payer contracts and service areas. If needed, contact additional Blue Plans for possible contracting opportunities.

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