Ancillary claims filing guidelines for providers

Health care providers should file claims for their Blue Cross and/or Blue Shield patients to the local Blue Plan, as traditionally defined. However, there are a few circumstances in which claims filing directions will differ, based on the type of provider and service. For these circumstances, the local Blue Plan is identified differently.

For ancillary services, the local Blue Plan is defined as follows:

• Independent Clinical Labs: All claims for clinical laboratory services provided to Blue Plan members must be submitted to the Blue Plan located in the state or service area where the specimen was drawn, regardless of where the specimen is analyzed. Where the specimen was drawn will be determined by the state of service area in which the referring provider is located. 
• Durable/Home Medical Equipment and Supplies (D/HME) and Orthotics & Prosthetics (O&P): All claims for DME and O&P provided to Blue Plan members must be submitted to the Blue Plan located in the state or service area to which the DME or O&P is shipped, or in which it is purchased at a retail store.
• Specialty Pharmacy: All claims for specialty pharmacy services provided to Blue Plan members must be submitted to the Blue Plan located in the state or service area where the ordering physician is located.

Note: Claims will be paid based on the provider’s participation status with the local Plan as defined above, regardless of the provider’s status with Blue Shield. 

For questions about filing ancillary claims under these requirements, call our BlueCard Claims Unit at (800) 622-0632.