Ancillary Claims Filing Mandate Billing Guidelines

Where do Labs, DME and Specialty Pharmacy Providers File Blue Claims?
BlueCross BlueShield Association requires all Blues plan to standardize the billing requirements for specific ancillary providers.

  • Ancillary providers included in the mandate are Independent Clinical Laboratory, Durable/Home Medical Equipment and Supplies and Specialty Pharmacy providers.

The mandate applies to all lines of business with the exception of FEP.

The mandate is being implemented by different plans at different times throughout 2012; however the final date for compliance for all plans is mid October 2012.

File the claim to the plan as noted below:

Independent Clinical Laboratory (Lab)

  • The Plan in the service area where the ordering/referring physician is located.

Durable/Home Medical Equipment and Supplies (DME)

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

Specialty Pharmacy

  • The Plan in the service area where the ordering/referring physician is located.

    NOTE: If the provider contracts with more than one Plan in the service area for the same product type (i.e., PPO or Traditional), they may file the claim with either Plan 
Provider Type How to File (Required Fields) Where to File Example
Independent Clinical Laboratory  (any type of non hospital based laboratory)
Types of Service include, but are not limited to:
Blood, urine, samples, analysis, etc.
Referring Provider:
- Field 17B on CMS 1500 Health Insurance Claim Form or
- Loop 2310A (claim level) on the 837 Professional Electronic
The Plan in the service area where the ordering/referring physician is located.

Blood is ordered by a physician located in RochesterBlood is drawn in WNY.  Blood analysis is done in Pennsylvania

File to: Excellus of Rochester.

Durable/Home Medical Equipment and Supplies (D/HME)
Types of Service include, but are not limited to:
Hospital beds, oxygen tanks, crutches, etc.

Patient’s Address:
- Field 5 on CMS 1500 Health Insurance Claim Form or
- Loop 2010CA on the 837 Professional Electronic Submission.

Ordering Provider:

- Field 17B on CMS 1500 Health Insurance Claim Form or
- Loop 2420E (line level) on the 837 Professional Electronic Submission.

Place of Service:

- Field 24B on the CMS 1500 Health Insurance Claim Form or Loop 2300, CLM05-1 on the 837 Professional Electronic Submissions.

Service Facility Location Information:

- Field 32 on CMS 1500 Health Insurance Form
or
- Loop 2310C (claim level) on the 837 Professional Electronic Submission.

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

A.   Wheelchair is purchased at a retail store in Buffalo NY.

File to: BCBS of WNY

B.   Wheelchair is purchased on the internet from an online retail supplier in California and shipped to Buffalo NY 

File to: BCBS of WNYC. Wheelchair is purchased at a retail store in Rochester and shipped to Michigan.  

File to: BCBS of WNY

Specialty Pharmacy

Types of Service:

Non-routine, biological therapeutics ordered by a healthcare professional as a covered medical benefit as defined by the member’s Plan’s Specialty Pharmacy formulary. Include, but are not limited to: injectable, infusion therapies, etc. 

Referring Provider:

- Field 17B on CMS 1500 Health Insurance Claim Form
or
- Loop 2310A (claim level) on the 837 Professional Electronic Submission.

The Plan in the service area where the ordering/referring  physician is located.

Patient is seen by a physician in Buffalo NY who orders a specialty pharmacy injectable for this patient.  Patient will receive the injections in Floridawhere the member lives for 6 months of the year. 

File to: BCBS of WNY

Which plan determines: Home Host
Coverage / Benefits x
Authorization / Medical Policy x
Billing specifics (i.e. modifiers, rental vs. purchase of DME items)
x
Reimbursement pricing
x
Appeals
x

1. The ancillary claim filing rules apply regardless of the provider’s contracting status with the Blue Plan where the claim is filed.

a. If the provider is not participating with the plan who receives the claim, it will be processed as Out of Network

2. Providers are encouraged to verify Member Eligibility and Benefits by contacting the phone number on the back of the Member ID card or call 1-800-676-BLUE, prior to providing any ancillary service.

3. Providers that utilize outside vendors to provide services (example: Sending blood specimen for special analysis that cannot be done by the Lab where the specimen was drawn) should utilize in-network participating Ancillary Providers to reduce the possibly of additional member liability for covered benefits.

4. 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 non-covered services. 

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