The MiraVista help desk gets a lot of questions about providing services to Blue Cross Blue Shield (BCBS) patients traveling from another state. With the holidays fast approaching, I thought it might be helpful to review the rules so DME suppliers can confidently service the influx of patients visiting their service area.
Blue Card Program
BCBS is a network of insurance plans, most of which cover specific states. The Blue Card program lets providers service any of the 115 million BCBS members via a single contract.
DME suppliers usually contract through the state plan where they operate, referred to as the “host” plan, and BCBS members are covered through the state plan where they live … the “home” plan.
Suppliers submit claims for covered services to their host plan, who then coordinates with the home plan for payment at the host plan’s contracted rates.
In general, suppliers should complete the following tasks before delivery to ensure proper coverage and reimbursement:
- Verify prior authorization requirements for the patient’s home plan website before providing service.
- Review the home plan’s medical policy for ordered products (coverage can vary by state or plan).
- Initiate required authorization electronically through Availity or the supplier’s preferred authorization portal.
Upon delivery, DME suppliers will submit claims to the host plan and receive payment from the home plan at the host plan’s contracted rates.
Multi-State Service Areas
Suppliers should file claims to the BCBS plan that covers the delivery address for the service. Many suppliers only need to contract with one BCBS plan because their service area and store locations are contained within a single state or territory. Suppliers with broader service areas, however, may need multiple BCBS contracts. I know this is a particular issue with my clients located close to state lines that routinely service patients in states on both sides.
In some cases, however, BCBS may direct suppliers to denote the place of service on the claims as 11 to signal an out-of-area customer transaction. When permitted by BCBS, suppliers may bill their host plan even though the patient will use the product outside its jurisdiction. The workaround does not allow suppliers to permanently expand their service area without separate contracting, but it does recognize that patients may occasionally cross state lines to visit nearby suppliers geographically covered by a different plan than the visiting consumer.