Name of Manual - Blue Cross and Blue Shield of Minnesota

Workers’ Compensation, No-Fault Auto &
Subrogation
Health Care Options
Overview Following is a Question and Answer guide to assist you in
reimbursement of Workers Compensation, No-Fault Auto and
Subrogation claims.
Workers'
Compensation, No-
Fault Auto &
Subrogation
1. What does Blue Cross need if the workers’ compensation
carrier, or the automobile carrier/third party liability
carrier denies?
We need a letter from the other carrier, stating the specific date
of service on the claim they are wanting paid and the reason
the other carrier is not paying claims.
2. Why do claims deny when they are not marked
work/auto/subro related?
Once we have identified a workers’ compensation or
automobile or subrogation claim, an indicator is placed on the
patient’s file. All claims that are possibly related to the
indicated injury are denied.
3. Why do claims continue to deny when a denial has been
sent in?
The denial must be valid in order for Blue Cross to pay the
claims under the health benefits. The denial is not valid unless
it specifies why the other insurance carrier is denying and they
provide a specific reason behind the denial such as doctor’s
opinion, IME, etc. If the denial is date specific, only the dates
listed on the denial are adjusted.
4. Why does Blue Cross need a denial from the workers’
compensation carrier if the doctor states it is not work
related?
A notification from the workers’ compensation carrier is
needed if the treatment is similar to the work injury. The
workers’ compensation carrier must make the final
determination.
5. Why do some claims pay and some deny?
If the diagnosis is non-specific (like pain in a limb) and we are
unable to determine what is being treated the claim may deny.
If we have limited information on what the injury is, some
claims may pay while others may deny.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10) 5-29