Blue Review
A newsletter for contracting institutional and professional providers

June 2019

Ancillary Claim Filing Guidelines and Reminders

Ancillary providers include Durable/Home Medical Equipment (DME/HME) and Supplies, Independent Clinical Laboratory, and Specialty/Home Infusion Therapy Pharmacies, among other types of providers. If you are an ancillary provider, we realize that your company may provide services to Blue Cross and Blue Shield (BCBS) members across the U.S., with local provider agreements with BCBS Plans in many states.

Quick Summary of Some Ancillary Claim Filing Guidelines
These guidelines are intended to help standardize claim filing procedures, regardless of your location.

  • DME/HME Providers – You must bill the BCBS Plan in whose service area the equipment was shipped to the member, rented or purchased at a retail store, regardless of any contracting arrangements that you may have with a BCBS Plan in another state.
  • Independent Clinical Laboratories – You must bill the BCBS Plan in whose service area the specimen is collected, even if your lab has a contract with a BCBS Plan in another state.
  • Specialty/Home Infusion Therapy Pharmacies – You must bill the BCBS Plan in the service area where the ordering physician is located, regardless of any contracting arrangements you may have with a BCBS Plan in another state.

Other Important Reminders

  • Always check eligibility and benefits to confirm membership/coverage details, prior to providing any ancillary service.
  • The ancillary claim filing rules apply regardless of the provider’s contracting status with the Blue Plan where the claim is filed.
  • If you contract with more than one Plan in a state for the same product type (i.e., PPO or Traditional), you may file the claim with either Plan. Contiguous county claim filing rules do not apply to ancillary claims.
  • If you use outside vendors to provide services (e.g., sending blood specimen for special analysis that cannot be done by the lab where the specimen was drawn), using in-network participating ancillary providers may reduce the possibility of additional member liability for covered benefits. To locate in-network participating providers, use our online Provider Finder®.
  • 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.

For more information, such as details on the data to include on your professional electronic (ANSI 837P) or paper (CMS-1500) claims, refer to the Ancillary Claims section of the BlueCard® Program Provider Manual. Ancillary claim filing guidelines and reminders for HMO and government programs members may differ from the information outlined in this article. If you have any questions, send an email to ancillarynetworks@bcbsil.com, or call 312-653-4820.

Checking eligibility and/or benefit information is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage applicable on the date services were rendered. If you have any questions, call the number on the member’s ID card.

The above material is for informational purposes only and is not intended to be a substitute for the independent medical judgment of a physician. Physicians and other health care providers are encouraged to use their own best medical judgment based upon all available information and the condition of the patient in determining the best course of treatment.