Blue cross blue shield bluecard ppo providers

• What is the BlueCard Program?

  The BlueCard® Program links participating healthcare providers and the independent Blue Cross and Blue Shield Plans across the country and abroad with a single electronic network for claims processing and reimbursement. The program allows participating providers in every state to submit almost all types of claims for out-of-state members to their local Blue Cross and Blue Shield Plan. This program eliminates your need to track money due from multiple Blue Cross and Blue Shield Plans as Blue Shield of California will process your reimbursement and provide you with an Explanation of Payment (EOP).

• Can providers who do not participate in the Blue Shield of California network submit claims?

  California providers that do not participate in the Blue Shield of California network may also send their claims to us; however, these providers may not receive in-network reimbursement from their local Blue plan and may still be required to bill the patient.

• What are the advantages of the BlueCard Program?

  The BlueCard Program eliminates the need for you to deal with multiple Blue Cross and/or Blue Shield Plans. Blue Shield of California is your single point of contact for BlueCard claims, payments, adjustments, service and claims-related inquiries.

• How do I identify BlueCard members?

  BlueCard members are easily identified by their ID cards. Ask to see the member’s ID card at each visit and share this information with your billing staff. Review these ID cards for the telephone number of the member’s Blue plan, claim filing addresses or for other instructions.

  There are three ID card elements you should look for to identify a BlueCard member:

  1. Plan logo: The presence of another Blue Cross and/or Blue Shield’s Plan logo on the member’s ID card is the first visual indicator that a member may be eligible for BlueCard benefits.
  2. Three-character prefix: The three-character prefix on the member’s ID card is the key element used to identify the plan to which the member belongs and to correctly route claims. It is critical to confirm membership, eligibility and coverage. If there is no prefix on a member’s ID card, that member is not eligible for benefits through the BlueCard Program.
  3. Suitcase logo: Members whose ID cards display the PPO in the suitcase logo are enrolled in PPO (Preferred Provider Organization) products. Benefits are delivered through the BlueCard Program. Members traveling or living outside their plan’s service area receive PPO-level benefits when they need services from participating physicians and other healthcare professionals. Members whose ID cards display the blank suitcase logo are enrolled in a product other than PPO. These members may also be eligible for BlueCard processing. Members whose ID cards do not display a suitcase logo are excluded from receiving benefits through the BlueCard Program.

• How do I submit BlueCard claims?

  Providers that participate in the Blue Shield of California network should submit BlueCard claims electronically. If you must send paper claims, use our Claims Routing Tool to find out where to send your claims.

  If you participate with another plan, please submit claims directly to that plan for processing.

• How are BlueCard claims processed?

  Once we receive your BlueCard claim, we will electronically route it to the out-of-state Blue Cross Blue Shield Plan that will process the claim according to the member's benefits contract. They will then authorize us to process the claim according to your local Blue Shield of California contract. Please make sure that you submit the claim with the appropriate prefix.

• How is the BlueCard Program administered?

  Blue Cross and Blue Shield network providers serve more than 100 million members nationwide, including more than 3 million members in the state of California. We understand the importance of ensuring easy administration for you, and we want your patients to have a positive experience with each visit.

  As a result, we are committed to meeting your needs and expectations by giving you a single point of contact through your local CA Blue plan for BlueCard claims, customer service and provider education-related inquiries.

• Are there additional provider resources for the BlueCard Program?

  If you have any questions about the BlueCard Program or filing claims for out-of-area patients, call our dedicated BlueCard claims unit at (800) 622-0632.

  Additional educational material for the BlueCard Program is available once you register and sign in to Provider Connection.

• What is the difference between the Home Plan and the Host Plan?

  The Home Plan is the Blue Cross and/or Blue Shield Plan through which the member is enrolled.

  The Host Plan is the Blue Cross and/or Blue Shield Plan in the area where services are rendered.

• Whom do I contact for information on a BlueCard claim?

  For BlueCard claims status and claims-related questions, Blue Shield of California’s claims unit can be reached at (800) 622-0632

• Are there BlueCard exclusions?

  The following services cannot be submitted through the BlueCard Program and must be submitted directly to the member's plan:

  • Stand-alone dental coverage
  • Stand-alone prescription drug coverage

  
  Also, certain independent clinical labs, durable/home medical equipment providers and specialty pharmacies must submit claims according to the ancillary claims filing requirements. More information about the ancillary claims filing requirements for these provider types can be found on Provider Connection’s Ancillary claims filing guidelines page.

• Whom do I contact for pre-certification of services for BlueCard members?

  The online EPA tool on Provider Connection enables you to access another state’s Blue plan provider portal to request electronic pre-service review and authorization approvals through a secure routing mechanism. On our EPA page, you have the options to seek:

  • Medical Policy Information – select this option to obtain medical policy for a service
  • Prior Authorization Information – select this option to determine if pre-service and pre-authorization is required for a service
  • Electronic Provider Access – select this option to submit a pre-certification and prior authorization request

• Are prefixes required when submitting BlueCard claims?

  Three-character prefixes are required when submitting BlueCard claims. The prefix on the member’s ID card is the key element used to identify the Blue plan to which the member belongs and to correctly route claims.

  If there is no prefix on a member’s ID card, that member may not be eligible for benefits through the BlueCard Program.

• Is it possible to receive a list of phone numbers for the different blue plans to call them for eligibility and benefits services?

  We ask that you to call (800) 676-BLUE (2583) to be auto-routed to the correct Blue plan for specific member eligibility and benefit information. A knowledgeable representative will assist you.

• How can I get assistance with payment issues for secondary Medicare claims?

  Call Blue Shield of California’s Claims unit at (800) 622-0632. A representative will assist you with secondary Medicare claims involving other Blue plans. Our experienced BlueCard representatives will work directly with the member’s Home Plan, on your behalf, until your questions are resolved.

  For additional information, visit our BlueCard resources page on Provider Connection. Or register for one of our BlueCard webinars on our BlueCard webinars page.

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