Servicing Out-of-Area Members: Contiguous Areas - Blue Shield of ...

Servicing Out-of-Area Blue MembersBlueShield ofNortheastern New YorkBlueCard 201May 31, 2011A presentation of the Blue Cross and Blue Shield Association. All rights reserved.

Servicing Out-of-Area Members: Overview• Contiguous Area Claim Filing• Overlapping Service Area Claim Filing• Ancillary Providers Claim Filing• Air Ambulance Providers• Pharmacy, Dental and Vision Providers• Telemedicine ProvidersA presentation of the Blue Cross and Blue Shield Association. All rights reserved.2

Contiguous Area Claim FilingContiguous Area Claim FilingA presentation of the Blue Cross and Blue Shield Association. All rights reserved.3

Contiguous Area Claim Filing: Note to Plans• A contiguous area is generally a border county in another Plan’s service area onecounty over from the Plan’s own service area.• Per Brand regulations, a Plan is permitted to use the Brands outside its service areawhen:– “Contracting with healthcare providers in a Contiguous Area in order to serve itssubscribers residing or working in the Licensee’s Service Area.”• Claims filing rules for contiguous area providers are based on the permitted terms of thecontiguous area contract, which may include:– The provider’s physical location.– The provider’s contract status with the two contiguous states.– The member’s Home Plan and where the member works or resides.– The location where the member received services.A presentation of the Blue Cross and Blue Shield Association. All rights reserved.4

Contiguous Area Example: Scenario OneProvider is located in one service area and has contracts withboth Plans.• Dr. Smith is located in Georgia (GA)and has a contract with GA.AlabamaGeorgiaLocalPlanA presentation of the Blue Cross and Blue Shield Association. All rights reserved.5

Contiguous Area Example: Scenario OneProvider is located in one service area and has contracts withboth Plans.• Dr. Smith is located in Georgia (GA)and has a contract with GA.• Dr. Smith also has a contiguousarea contract with Alabama (AL).AlabamaGeorgiaA presentation of the Blue Cross and Blue Shield Association. All rights reserved.6

Contiguous Area Example: Scenario OneProvider is located in one service area and has contracts withboth Plans.• Dr. Smith is located in Georgia (GA)and has a contract with GA.• Dr. Smith also has a contiguousarea contract with Alabama (AL).AlabamaGeorgia• Dr. Smith files a claim to AL for anAL member who resides or works inAL to AL. It is a local AL in-networkclaim.LocalPlanclaimAL memberA presentation of the Blue Cross and Blue Shield Association. All rights reserved.7

Contiguous Area Example: Scenario OneProvider is located in one service area and has contracts withboth Plans.• Dr. Smith is located in Georgia (GA)and has a contract with GA.• Dr. Smith also has a contiguousarea contract with Alabama (AL).AlabamaGeorgia• Dr. Smith files a claim for an ALmember who resides or works in ALto AL. It is a local AL in-networkclaim.• Dr. Smith files a GA member's claimto GA. It is a local GA in-network claim.LocalPlanclaimLocalPlanclaimAL memberGA memberA presentation of the Blue Cross and Blue Shield Association. All rights reserved.8

Contiguous Area Example: Scenario OneProvider is located in one service area and has contracts withboth Plans.• Dr. Smith is located in Georgia (GA)and has a contract with GA.• Dr. Smith also has a contiguousarea contract with Alabama (AL).AlabamaGeorgia• Dr. Smith files a claim to AL for anAL member who resides or works inAL. It is a local AL in-network claim.HostPlan• Dr. Smith files a GA member's claimto GA. It is a local GA in-network claim.• Dr. Smith files claims for an AL memberwho doesn’t reside or work in AL or anyother Plan’s member to GA; regularBlueCard claims filing rules apply.It is a BlueCard in-network claim.A presentation of the Blue Cross and Blue Shield Association. All rights reserved.IL member-OR-AL member9

Contiguous Area Example: Scenario TwoProvider is located in one service area and has a contract onlywith the Plan in this service area.• Dr. Smith is located in GA and has acontract with GA.AlabamaGeorgiaA presentation of the Blue Cross and Blue Shield Association. All rights reserved.10

Contiguous Area Example: Scenario TwoProvider is located in one service area and has a contract onlywith the Plan in this service area.• Dr. Smith is located in GA and has acontract with GA.• Dr. Smith has no contiguous areacontract with AL.AlabamaGeorgiaA presentation of the Blue Cross and Blue Shield Association. All rights reserved.11

Contiguous Area Example: Scenario TwoProvider is located in one service area and has a contract onlywith the Plan in this service area.• Dr. Smith is located in GA and has acontract with GA.• Dr. Smith has no contiguous areacontract with AL.AlabamaGeorgia• Dr. Smith files a GA member's claim toGA. It is a local GA in-network claim.LocalPlanclaimGA memberA presentation of the Blue Cross and Blue Shield Association. All rights reserved.12

Contiguous Area Example: Scenario TwoProvider is located in one service area and has a contract onlywith the Plan in this service area.• Dr. Smith is located in GA and has acontract with GA.• Dr. Smith has no contiguous areacontract with AL.AlabamaGeorgia• Dr. Smith files a GA member's claim toGA. It is a local GA in-network claim.LocalPlan• Dr. Smith files claims for an ALmember and any other Plan’smember to GA; regular BlueCardclaims filing rules apply. It is aBlueCard in-network claim.-OR-A presentation of the Blue Cross and Blue Shield Association. All rights reserved.IL memberAL member13

Contiguous Area Example: Scenario ThreeProvider is located in one service area, has no contract with thePlan in this area, and has a contiguous county contract with theother Plan.• Dr. Smith is located in GA and has nocontract with GA.AlabamaGeorgiaA presentation of the Blue Cross and Blue Shield Association. All rights reserved.14

Contiguous Area Example: Scenario ThreeProvider is located in one service area, has no contract with thePlan in this area, and has a contiguous county contract with theother Plan.• Dr. Smith is located in GA and has nocontract with GA.• Dr. Smith has a contiguous areacontract with AL.AlabamaGeorgiaA presentation of the Blue Cross and Blue Shield Association. All rights reserved.15

Contiguous Area Example: Scenario ThreeProvider is located in one service area, has no contract with thePlan in this area, and has a contiguous county contract with theother Plan.• Dr. Smith is located in GA and has nocontract with GA.AlabamaGeorgia• Dr. Smith has a contiguous areacontract with AL.• Dr. Smith files a claim to AL for an ALmember who resides or works in AL.It is a local AL in-network claim.LocalPlanclaimAL memberA presentation of the Blue Cross and Blue Shield Association. All rights reserved.16

Contiguous Area Example: Scenario ThreeProvider is located in one service area, has no contract with thePlan in this area, and has a contiguous county contract with theother Plan.• Dr. Smith is located in GA and has nocontract with GA.AlabamaGeorgia• Dr. Smith has a contiguous areacontract with AL.• Dr. Smith files a claim for an ALmember who resides or works in AL toAL.It is a local AL in-network claim.LocalPlanLocalPlan• Dr. Smith files a claim for a GA memberto GA. It is a local GA out-of-networkclaim.claimclaimA presentation of the Blue Cross and Blue Shield Association. All rights reserved.AL memberGA member17

Contiguous Area Example: Scenario ThreeProvider is located in one service area, has no contract with thePlan in this area, and has a contiguous county contract with theother Plan.• Dr. Smith is located in GA and has nocontract with GA.• Dr. Smith has a contiguous areacontract with AL.AlabamaGeorgia• Dr. Smith files a claim to AL for an ALmember who resides or works in AL.It is a local AL in-network claim.HostPlan• Dr. Smith files a claim for a GA memberto GA. It is a local GA out-of-networkclaim.• Dr. Smith files claims to GA for ILmember or AL member who doesn’treside or work in AL; regular BlueCardclaim filing rules apply. It is a BlueCardout-of-network claim.A presentation of the Blue Cross and Blue Shield Association. All rights reserved.-OR-IL member AL member18

Contiguous Area Example: Scenario FourProvider is located in both service areas and has contracts withPlans in both service areas.• Dr. Smith has an office in GA in an areacontiguous to AL and an office in ALin an area contiguous to GA.AlabamaGeorgiaA presentation of the Blue Cross and Blue Shield Association. All rights reserved.19

Contiguous Area Example: Scenario FourProvider is located in both service areas and has contracts withPlans in both service areas.• Dr. Smith has an office in GA in an areacontiguous to AL and an office in ALin an area contiguous to GA.• Dr. Smith has a contract with AL;Dr. Smith has a contract with GA.AlabamaGeorgiaA presentation of the Blue Cross and Blue Shield Association. All rights reserved.20

Contiguous Area Example: Scenario FourProvider is located in both service areas and has contracts withPlans in both service areas.• Dr. Smith has an office in GA in an areacontiguous to AL and an office in AL inan area contiguous to GA.• Dr. Smith has a contract with AL;Dr. Smith has a contract with GA.• Dr. Smith sees a GA member in hisGA office. The claim is filed to GA.It is a local GA in-network claim.AlabamaGeorgiaLocalPlanclaimGA memberA presentation of the Blue Cross and Blue Shield Association. All rights reserved.21

Contiguous Area Example: Scenario FourProvider is located in both service areas and has contracts withPlans in both service areas.• Dr. Smith has an office in GA in an areacontiguous to AL and an office in ALin an area contiguous to GA.• Dr. Smith has a contract with AL;Dr. Smith has a contract with GA.• Dr. Smith sees a GA member in hisGA office. The claim is filed to GA.It is a local GA in-network claim.• Dr. Smith sees an AL member whoresides or works in AL in his GA office.The claim is filed to AL. It is a local ALin-network claim.AlabamaLocalPlanclaimGeorgiaLocalPlanclaimAL memberGA memberA presentation of the Blue Cross and Blue Shield Association. All rights reserved.22

Contiguous Area Example: Scenario FourProvider is located in both service areas and has contracts withPlans in both service areas.• Dr. Smith has an office in GA in an areacontiguous to AL and an office in ALin an area contiguous to GA.• Dr. Smith has a contract with AL;Dr. Smith has a contract with GA.• Dr. Smith sees a GA member in hisGA office. The claim is filed to GA.It is a local GA in-network claim.• Dr. Smith sees an AL member whoresides or works in AL in his GA office.The claim is filed to AL. It is a local AL innetworkclaim.• Dr. Smith sees an IL member or ALmember, not residing or workingin AL, in his GA office. The claim is filedto GA; regular BlueCard claim filingrules apply. It is a BlueCard in-networkclaim.A presentation of the Blue Cross and Blue Shield Association. All rights reserved.AlabamaGeorgiaIL memberLocal HostPlan-OR-AL member23

Contiguous Area Example: Scenario FiveProvider is located in both service areas and has a contract withone Plan.• Dr. Smith has an office in GA in anarea contiguous to AL and an officein AL in an area contiguous to GA.AlabamaGeorgiaA presentation of the Blue Cross and Blue Shield Association. All rights reserved.24

Contiguous Area Example: Scenario FiveProvider is located in both service areas and has a contract withone Plan.• Dr. Smith has an office in GA in anarea contiguous to AL and an officein AL in an area contiguous to GA.• Dr. Smith has a contract with GA butdoes not have a contract with AL.AlabamaGeorgiaA presentation of the Blue Cross and Blue Shield Association. All rights reserved.25

Contiguous Area Example: Scenario FiveProvider is located in both service areas and has a contract withone Plan.• Dr. Smith has an office in GA in anarea contiguous to AL and an officein AL in an area contiguous to GA.• Dr. Smith has a contract with GA butdoes not have a contract with AL.AlabamaGeorgia• Dr. Smith sees a GA member in hisGA office. The claim is filed to GA.It is a local GA in-network claim.LocalPlanclaimA presentation of the Blue Cross and Blue Shield Association. All rights reserved.GA member26

Contiguous Area Example: Scenario FiveProvider is located in both service areas and has a contract withone Plan.• Dr. Smith has an office in GA in anarea contiguous to AL and an officein AL in an area contiguous to GA.• Dr. Smith has a contract with GA butdoes not have a contract with AL.AlabamaGeorgia• Dr. Smith sees a GA member in hisGA office. The claim is filed to GA.It is a local GA in-network claim.• Dr. Smith sees any other Planmember (IL or AL) in his GA office.The claim is filed to GA; regularBlueCard claim filing rules apply.It is a BlueCard in-network claim.HostPlan-OR-A presentation of the Blue Cross and Blue Shield Association. All rights reserved.IL memberAL member27

Contiguous Area Example: Scenario Five (continued)Provider is located in both service areas and has a contract withone Plan.• Dr. Smith has an office in GA in anarea contiguous to AL and in ALin an area contiguous to GA.AlabamaGeorgiaA presentation of the Blue Cross and Blue Shield Association. All rights reserved.28

Contiguous Area Example: Scenario Five (continued)Provider is located in both service areas and has a contract withone Plan.• Dr. Smith has an office in GA in anarea contiguous to AL and in ALin an area contiguous to GA.• Dr. Smith has a contract with GA butdoes not have a contract with AL.AlabamaGeorgiaA presentation of the Blue Cross and Blue Shield Association. All rights reserved.29

Contiguous Area Example: Scenario Five (continued)Provider is located in both service areas and has a contract withone Plan.• Dr. Smith has an office in GA in anarea contiguous to AL and in ALin an area contiguous to GA.• Dr. Smith has a contract with GA butdoes not have a contract with AL.AlabamaGeorgia• Dr. Smith sees an AL member in hisAL office. The claim is filed to AL.It is a local AL out-of-network claim.LocalPlanclaimAL memberA presentation of the Blue Cross and Blue Shield Association. All rights reserved.30

Contiguous Area Example: Scenario Five (continued)Provider is located in both service areas and has a contract withone Plan.• Dr. Smith has an office in GA in anarea contiguous to AL and in ALin an area contiguous to GA.• Dr. Smith has a contract with GA butdoes not have a contract with AL.AlabamaGeorgia• Dr. Smith sees an AL member in hisAL office. The claim is filed to AL.It is a local AL out-of-network claim.HostPlan• Dr. Smith sees any other Plan’smember (IL or GA) in his AL office;the claim is filed to AL; regularBlueCard claim filing rules apply.It is a BlueCard out-of-network claim.-OR-A presentation of the Blue Cross and Blue Shield Association. All rights reserved.GA memberIL member31

Contiguous Area Example: Scenario SixProvider is located in both service areas and has no contractswith either Plan.• Dr. Smith has an office in GA in an areacontiguous to AL and in AL in an areacontiguous to GA.AlabamaGeorgiaA presentation of the Blue Cross and Blue Shield Association. All rights reserved.32

Contiguous Area Example: Scenario SixProvider is located in both service areas and has no contractswith either Plan.• Dr. Smith has an office in GA in an areacontiguous to AL and in AL in an areacontiguous to GA.• Dr. Smith has no contract with GA and nocontract with AL.AlabamaGeorgiaA presentation of the Blue Cross and Blue Shield Association. All rights reserved.33

Contiguous Area Example: Scenario SixProvider is located in both service areas and has no contractswith either Plan.• Dr. Smith has an office in GA in an areacontiguous to AL and in AL in an areacontiguous to GA.• Dr. Smith has no contract with GA and nocontract with AL.AlabamaGeorgia• Dr. Smith sees a GA member in his GAoffice. The claim is filed to GA. It is a localGA out-of-network claim.LocalPlanclaimA presentation of the Blue Cross and Blue Shield Association. All rights reserved.GA member34

Contiguous Area Example: Scenario SixProvider is located in both service areas and has no contractswith either Plan.• Dr. Smith has an office in GA in an areacontiguous to AL and in AL in an areacontiguous to GA.• Dr. Smith has no contract with GA and nocontract with AL.AlabamaGeorgia• Dr. Smith sees a GA member in his GAoffice. The claim is filed to GA. It is a localGA out-of-network claim.• Dr. Smith sees any other Plan member(IL or AL) in his GA office; the claim is filedto GA; regular BlueCard claim filing rulesapply. It is a BlueCard out-of-network claim.HostPlan-OR-A presentation of the Blue Cross and Blue Shield Association. All rights reserved.IL memberAL member35

Contiguous Area Example: Scenario SixProvider is located in both service areas and has no contractswith either Plan.• Dr. Smith has an office in GA in an areacontiguous to AL and in AL in an areacontiguous to GA.• Dr. Smith has no contract with GA and nocontract with AL.AlabamaGeorgia• Dr. Smith sees a GA member in his GAoffice. The claim is filed to GA. It is a localGA out-of-network claim.• Dr. Smith sees any other Plan member(IL or AL) in his GA office; the claim is filedto GA; regular BlueCard claim filing rulesapply. It is a BlueCard out-of-network claim.• Dr. Smith sees an AL member in his ALoffice. The claim is filed to AL. It is a localAL out-of-network claim.LocalPlanclaimAL memberA presentation of the Blue Cross and Blue Shield Association. All rights reserved.36

Contiguous Area Example: Scenario SixProvider is located in both service areas and has no contractswith either Plan.• Dr. Smith has an office in GA in an areacontiguous to AL and in AL in an areacontiguous to GA.• Dr. Smith has no contract with GA and nocontract with AL.AlabamaGeorgia• Dr. Smith sees a GA member in his GAoffice. The claim is filed to GA. It is a localGA out-of-network claim.• Dr. Smith sees any other Plan member(IL or AL) in his GA office; the claim is filedto GA; regular BlueCard claim filing rulesapply. It is a BlueCard out-of-network claim.HostPlan• Dr. Smith sees an AL member in his ALoffice. The claim is filed to AL. It is a localAL out-of-network claim.• Dr. Smith sees any other Plan member(IL or GA) in his AL office; the claim isfiled to AL; regular BlueCard claim filingrules apply. It is a BlueCard out-ofnetworkclaim.A presentation of the Blue Cross and Blue Shield Association. All rights reserved.GA member-OR-IL member37

Overlapping Service Areas Claim FilingOverlapping Service Areas Claim FilingA presentation of the Blue Cross and Blue Shield Association. All rights reserved.

Overlapping Service Areas Claims Filing:Note to Plans• An overlapping service area is a geographic area in which more than oneLicensee is authorized to use the Brands.• There are five states that have more than one Blue Plan operating within itsgeographic area. Plans operating in the overlapping service areas include:– In California, Anthem Blue Cross (WellPoint) and Blue Shield of California.– In Idaho, Blue Cross of Idaho and Regence BlueShield of Idaho.– In New York, BlueShield of Northeastern New York (HealthNow) and BlueCrossBlueShield of Western New York (HealthNow), Excellus and Empire (part ofWellPoint).– In Pennsylvania, Highmark Blue Cross Blue Shield, Capital Blue Cross, Blue Crossof Northeastern Pennsylvania and Independence Blue Cross.– In Washington, there are Premera Blue Cross, Regence Blue Shield, and RegenceBlueShield of Idaho.A presentation of the Blue Cross and Blue Shield Association. All rights reserved.39

Overlapping Service Area: Scenario OneProvider is located in an overlapping service area and hiscontracting status with the local Plans is irrelevant.• Dr. Smith is located in California (CA).CaliforniaA presentation of the Blue Cross and Blue Shield Association. All rights reserved.40

Overlapping Service Area: Scenario OneProvider is located in an overlapping service area and hiscontracting status with the local Plans is irrelevant.• Dr. Smith is located in California (CA).• Dr. Smith may or may not have contractswith Anthem Blue Cross (CA) and/or BlueShield of CA.CaliforniaandA presentation of the Blue Cross and Blue Shield Association. All rights reserved.41

Overlapping Service Area: Scenario OneProvider is located in an overlapping service area and hiscontracting status with the local Plans is irrelevant.• Dr. Smith is located in California (CA).• Dr. Smith may or may not have contractswith Anthem Blue Cross (CA) and/or BlueShield of CA.• Dr. Smith sees Blue Shield of CA member.The claim is filed to Blue Shield of CA.It is a local Blue Shield of CA in-networkor out-of-network claim.LocalPlanclaimCaliforniaandBS (CA) memberA presentation of the Blue Cross and Blue Shield Association. All rights reserved.42

Overlapping Service Area: Scenario OneProvider is located in an overlapping service area and hiscontracting status with the local Plans is irrelevant.• Dr. Smith is located in California (CA).• Dr. Smith may or may not have contractswith Anthem Blue Cross (CA) and/or BlueShield of CA.• Dr. Smith sees a Blue Shield of CA member.The claim is filed to Blue Shield of CA.It is a local Blue Shield of CA in-networkor out-of-network claim.• Dr. Smith sees an Anthem Blue Cross member.The claim is filed to Anthem BC (CA). It is a localAnthem BC in-network or out-of-network claim.LocalPlanclaimCaliforniaandA presentation of the Blue Cross and Blue Shield Association. All rights reserved.BC (CA) memberBS (CA) member43

Overlapping Service Area: Scenario OneProvider is located in an overlapping service area and hiscontracting status with the local Plans is irrelevant.• Dr. Smith is located in California (CA).• Dr. Smith may or may not have contractswith Anthem Blue Cross (CA) and/or BlueShield of CA.• Dr. Smith sees a Blue Shield of CA member.The claim is filed to Blue Shield of CA.It is a local Blue Shield of CA in-networkor out-of-network claim.• Dr. Smith sees an Anthem Blue Cross member.The claim is filed to Anthem BC (CA). It is a localAnthem BC in-network or out-of-network claim.LocalPlanclaimCaliforniaand• Overlapping Plans cannot serve as a Homeand/or Host Plan to each other’s members.A presentation of the Blue Cross and Blue Shield Association. All rights reserved.BC (CA) memberBS (CA) member44

Overlapping Service Area: Scenario TwoProvider is located in an overlapping service area andhas a contract with one Plan.• Dr. Smith is located in California (CA).CaliforniaA presentation of the Blue Cross and Blue Shield Association. All rights reserved.45

Overlapping Service Area: Scenario TwoProvider is located in an overlapping service area andhas a contract with one Plan.• Dr. Smith is located in California (CA).• Dr. Smith has a contract with Anthem Blue Cross(CA) and no contract with Blue Shield of CA.CaliforniaandA presentation of the Blue Cross and Blue Shield Association. All rights reserved.46

Overlapping Service Area: Scenario TwoProvider is located in an overlapping service area andhas a contract with one Plan.• Dr. Smith is located in California (CA).• Dr. Smith has a contract with Anthem Blue Cross(CA) and no contract with Blue Shield of CA.• Dr. Smith sees an Anthem Blue Cross member.The claim is filed to Anthem BC (CA). It is a localAnthem BC in-network claim.LocalPlanCaliforniaandclaimBC (CA) memberA presentation of the Blue Cross and Blue Shield Association. All rights reserved.47

Overlapping Service Area: Scenario TwoProvider is located in an overlapping service area andhas a contract with one Plan.• Dr. Smith is located in California (CA).• Dr. Smith has a contract with Anthem Blue Cross(CA) and no contract with Blue Shield of CA.• Dr. Smith sees an Anthem Blue Cross member.The claim is filed to Anthem BC (CA). It is a localAnthem BC in-network claim.• Dr. Smith sees a Blue Shield of CA member. The claimis filed to Blue Shield of CA. It is a local Blue Shield ofCA out-of-network claim.LocalPlanclaimCaliforniaandBS (CA) memberA presentation of the Blue Cross and Blue Shield Association. All rights reserved.48

Overlapping Service Area: Scenario TwoProvider is located in an overlapping service area andhas a contract with one Plan.• Dr. Smith is located in California (CA).• Dr. Smith has a contract with Anthem Blue Cross(CA) and no contract with Blue Shield of CA.• Dr. Smith sees an Anthem Blue Cross member.The claim is filed to Anthem BC (CA). It is a localAnthem BC in-network claim.• Dr. Smith sees a Blue Shield of CA member. The claimis filed to Blue Shield of CA. It is a local Blue Shield ofCA out-of-network claim.HostPlanCaliforniaand• Dr. Smith sees an IL member. The claim is filed toAnthem BC (CA). It is a BlueCard, in-network claim.IL memberA presentation of the Blue Cross and Blue Shield Association. All rights reserved.49

Overlapping Service Area: Scenario TwoProvider is located in an overlapping service area andhas a contract with one Plan.• Dr. Smith is located in California (CA).• Dr. Smith has a contract with Anthem Blue Cross(CA) and no contract with Blue Shield of CA.• Dr. Smith sees an Anthem Blue Cross member.The claim is filed to Anthem BC (CA). It is a localAnthem BC in-network claim.• Dr. Smith sees a Blue Shield of CA member. The claimis filed to Blue Shield of CA. It is a local Blue Shield ofCA out-of-network claim.HostPlanCaliforniaand• Dr. Smith sees an IL member. The claim is filed toAnthem BC (CA). It is a BlueCard, in-network claim.• Note: All Plans operating in multiple service areas areconsidered one service area, for example, allWellPoint (Anthem) Plans are one service area, sowhen Dr. Smith in CA sees a member from anotherWellPoint Plan, e.g., CO, WI or GA, the claim is a localclaim and should be filed to Anthem Blue Cross in CA.A presentation of the Blue Cross and Blue Shield Association. All rights reserved.IL member50

Overlapping Service Area: Scenario ThreeProvider is located in an overlapping service area and hascontracts with both Plans. The contracts are for the sameproduct that the member has.• Dr. Smith is located in California (CA).CaliforniaA presentation of the Blue Cross and Blue Shield Association. All rights reserved.51

Overlapping Service Area: Scenario ThreeProvider is located in an overlapping service area and hascontracts with both Plans. The contracts are for the sameproduct that the member has.• Dr. Smith is located in California (CA).• Dr. Smith has a PPO contract with AnthemBlue Cross (CA) and a PPO contract withBlue Shield of CA.CaliforniaandA presentation of the Blue Cross and Blue Shield Association. All rights reserved.52

Overlapping Service Area: Scenario ThreeProvider is located in an overlapping service area and hascontracts with both Plans. The contracts are for the sameproduct that the member has.• Dr. Smith is located in California (CA).• Dr. Smith has a PPO contract with AnthemBlue Cross (CA) and a PPO contract withBlue Shield of CA.• Dr. Smith sees an Anthem BC (CA) member(PPO or non-PPO). The claim is filed toAnthem BC (CA). It is a local claim.LocalPlanCaliforniaandclaimBC (CA) memberA presentation of the Blue Cross and Blue Shield Association. All rights reserved.53

Overlapping Service Area: Scenario ThreeProvider is located in an overlapping service area and hascontracts with both Plans. The contracts are for the sameproduct that the member has.• Dr. Smith is located in California (CA).• Dr. Smith has a PPO contract with AnthemBlue Cross (CA) and a PPO contract withBlue Shield of CA.• Dr. Smith sees an Anthem BC (CA) member(PPO or non-PPO). The claim is filed toAnthem BC (CA). It is a local claim.LocalPlanCaliforniaand• Dr. Smith sees a Blue Shield of Californiamember (PPO or non-PPO). The claim is filedto Blue Shield of CA. It is a local claim.claimBS (CA) memberA presentation of the Blue Cross and Blue Shield Association. All rights reserved.54

Overlapping Service Area: Scenario ThreeProvider is located in an overlapping service area and hascontracts with both Plans. The contracts are for the sameproduct that the member has.• Dr. Smith is located in California (CA).• Dr. Smith has a PPO contract with AnthemBlue Cross (CA) and a PPO contract withBlue Shield of CA.• Dr. Smith sees an Anthem BC (CA) member(PPO or non-PPO). The claim is filed toAnthem BC (CA). It is a local claim.HostPlanCaliforniaand• Dr. Smith sees a Blue Shield of Californiamember (PPO or non-PPO). The claim is filedto Blue Shield of CA. It is a local claim.• Dr. Smith sees an IL PPO member. The claimis filed to either of the CA Plans, because theprovider has PPO contracts with both Plans.Regular BlueCard claim filing rules apply. It isa BlueCard in-network claim.IL memberA presentation of the Blue Cross and Blue Shield Association. All rights reserved.55

Overlapping Service Area: Scenario FourProvider is located in an overlapping service area and hascontracts with both Plans for different products than what themember has.• Dr. Smith is located in California (CA).CaliforniaA presentation of the Blue Cross and Blue Shield Association. All rights reserved.56

Overlapping Service Area: Scenario FourProvider is located in an overlapping service area and hascontracts with both Plans for different products than what themember has.• Dr. Smith is located in California (CA).• Dr. Smith has a PPO contract with AnthemBlue Cross (CA) and a Traditional contractwith Blue Shield of CA.CaliforniaandA presentation of the Blue Cross and Blue Shield Association. All rights reserved.57

Overlapping Service Area: Scenario FourProvider is located in an overlapping service area and hascontracts with both Plans for different products than what themember has.• Dr. Smith is located in California (CA).• Dr. Smith has a PPO contract with AnthemBlue Cross (CA) and a Traditional contractwith Blue Shield of CA.HostPlanCaliforniaand• Dr. Smith sees an IL POS member. Theclaim is filed to either of the CA Plansbecause Dr. Smith has contracts with bothPlans; regular BlueCard claim filing rulesapply. It is a BlueCard claim.IL memberA presentation of the Blue Cross and Blue Shield Association. All rights reserved.58

A presentation of the Blue Cross and Blue Shield Association. All rights reserved.Ancillary Providers Claim FilingAncillary Providers Claim Filing

Ancillary Providers: Claim FilingAncillary providers’ claims are filed with the local Planas follows:Lab ProviderLab ProviderWhere the specimenwas collected.Durable/Home MedicalDurable/Home MedicalEquipment ProviderEquipment ProviderWhere the equipmentor supplies were delivered oror purchased.Specialty PharmacySpecialty PharmacyProviderProviderWhere the orderingphysician is located.A presentation of the Blue Cross and Blue Shield Association. All rights reserved.60

Remote Ancillary Providers: Scenario OneNote: The following scenarios are applicable to ancillary providers(Lab, DME/HME and Specialty Pharmacy).• Lab provider is located in North Dakota (ND)and contracts with BCBS of ND.North DakotaA presentation of the Blue Cross and Blue Shield Association. All rights reserved.61

Remote Ancillary Providers: Scenario OneNote: The following scenarios are applicable to ancillary providers(Lab, DME/HME and Specialty Pharmacy).• Lab provider is located in North Dakota (ND)and contracts with BCBS of ND.North Dakota• BCBS of Hawaii (HI) has a remote providercontract with this provider for specimensdrawn in HI.HawaiiA presentation of the Blue Cross and Blue Shield Association. All rights reserved.62

Remote Ancillary Providers: Scenario OneNote: The following scenarios are applicable to ancillary providers(Lab, DME/HME and Specialty Pharmacy).• Lab provider is located in North Dakota (ND)and contracts with BCBS of ND.North Dakota• BCBS of Hawaii (HI) has a remote providercontract with this provider for specimensdrawn in HI.• BCBS of Alabama (AL) memberhas a specimen drawn in HI.HawaiiAL memberA presentation of the Blue Cross and Blue Shield Association. All rights reserved.63

Remote Ancillary Providers: Scenario OneNote: The following scenarios are applicable to ancillary providers(Lab, DME/HME and Specialty Pharmacy).• Lab provider is located in North Dakota (ND)and contracts with BCBS of ND.North Dakota• BCBS of Hawaii (HI) has a remote providercontract with this provider for specimensdrawn in HI.HostPlan• BCBS of Alabama (AL) memberhas a specimen drawn in HI.Hawaii• Lab provider files a claim to BCBS of HI. Itis a BlueCard in-network claim.AL memberA presentation of the Blue Cross and Blue Shield Association. All rights reserved.64

Remote Ancillary Providers: Scenario TwoNote: The following scenarios are applicable to ancillary providers(Lab, DME/HME and Specialty Pharmacy).• Lab provider is located in ND andcontracts with BCBS of ND.North DakotaA presentation of the Blue Cross and Blue Shield Association. All rights reserved.65

Remote Ancillary Providers: Scenario TwoNote: The following scenarios are applicable to ancillary providers(Lab, DME/HME and Specialty Pharmacy).• Lab provider is located in ND andcontracts with BCBS of ND.North Dakota• BCBS of HI does not have a remoteprovider contract with this provider forspecimens drawn in HI.HawaiiA presentation of the Blue Cross and Blue Shield Association. All rights reserved.66

Remote Ancillary Providers: Scenario TwoNote: The following scenarios are applicable to ancillary providers(Lab, DME/HME and Specialty Pharmacy).• Lab provider is located in ND andcontracts with BCBS of ND.North Dakota• BCBS of HI does not have a remoteprovider contract with this provider forspecimens drawn in HI.• BCBS of AL member has a specimendrawn in HI.HawaiiAL memberA presentation of the Blue Cross and Blue Shield Association. All rights reserved.67

Remote Ancillary Providers: Scenario TwoNote: The following scenarios are applicable to ancillary providers(Lab, DME/HME and Specialty Pharmacy).• Lab provider is located in ND andcontracts with BCBS of ND.North Dakota• BCBS of HI does not have a remoteprovider contract with this provider forspecimens drawn in HI.HostPlan• BCBS of AL member has a specimendrawn in HI.Hawaii• Lab provider files a claim to BCBSof HI. It is a BlueCard out-ofnetworkclaim.AL memberA presentation of the Blue Cross and Blue Shield Association. All rights reserved.68

Remote Ancillary Providers: Scenario ThreeNote: The following scenarios are applicable to ancillary providers(Lab, DME/HME and Specialty Pharmacy).• Lab provider is located in ND and does notcontract with BCBS of ND.North DakotaA presentation of the Blue Cross and Blue Shield Association. All rights reserved.69

Remote Ancillary Providers: Scenario ThreeNote: The following scenarios are applicable to ancillary providers(Lab, DME/HME and Specialty Pharmacy).• Lab provider is located in ND and does notcontract with BCBS of ND.North Dakota• BCBS of HI does not have a remote providercontract with the lab company for specimensdrawn in HI.HawaiiA presentation of the Blue Cross and Blue Shield Association. All rights reserved.70

Remote Ancillary Providers: Scenario ThreeNote: The following scenarios are applicable to ancillary providers(Lab, DME/HME and Specialty Pharmacy).• Lab provider is located in ND and does notcontract with BCBS of ND.North Dakota• BCBS of HI does not have a remote providercontract with the lab company for specimensdrawn in HI.• BCBS of AL member has a specimendrawn in HI.HawaiiAL memberA presentation of the Blue Cross and Blue Shield Association. All rights reserved.71

Remote Ancillary Providers: Scenario ThreeNote: The following scenarios are applicable to ancillary providers(Lab, DME/HME and Specialty Pharmacy).• Lab provider is located in ND and does notcontract with BCBS of ND.North Dakota• BCBS of HI does not have a remote providercontract with the lab company for specimensdrawn in HI.HostPlan• BCBS of AL member has a specimendrawn in HI.• Lab provider files a claim to BCBS ofHI. It is a BlueCard out-of-networkclaim.HawaiiAL memberA presentation of the Blue Cross and Blue Shield Association. All rights reserved.72

Remote Ancillary Providers: Scenario FourNote: The following scenarios are applicable to ancillary providers(Lab, DME/HME and Specialty Pharmacy).• Lab provider is located in ND andcontracts with BCBS of ND.North DakotaA presentation of the Blue Cross and Blue Shield Association. All rights reserved.73

Remote Ancillary Providers: Scenario FourNote: The following scenarios are applicable to ancillary providers(Lab, DME/HME and Specialty Pharmacy).• Lab provider is located in ND andcontracts with BCBS of ND.North Dakota• BCBS of HI has a remote provider contractwith the lab company for specimens drawnin HI.NebraskaHawaiiA presentation of the Blue Cross and Blue Shield Association. All rights reserved.74

Remote Ancillary Providers: Scenario FourNote: The following scenarios are applicable to ancillary providers(Lab, DME/HME and Specialty Pharmacy).• Lab provider is located in ND andcontracts with BCBS of ND.• BCBS of HI has a remote provider contractwith the lab company for specimens drawnin HI.• BCBS of NE has a remote providercontract with the lab company forspecimens drawn in Nebraska (NE).North DakotaNebraskaHawaiiA presentation of the Blue Cross and Blue Shield Association. All rights reserved.75

Remote Ancillary Providers: Scenario FourNote: The following scenarios are applicable to ancillary providers(Lab, DME/HME and Specialty Pharmacy).• Lab provider is located in ND andcontracts with BCBS of ND.• BCBS of HI has a remote provider contractwith the lab company for specimens drawnin HI.• BCBS of NE has a remote providercontract with the lab company forspecimens drawn in Nebraska (NE).North DakotaNebraska• BCBS of AL member has a specimendrawn in HI.HawaiiA presentation of the Blue Cross and Blue Shield Association. All rights reserved.AL member76

Remote Ancillary Providers: Scenario FourNote: The following scenarios are applicable to ancillary providers(Lab, DME/HME and Specialty Pharmacy).• Lab provider is located in ND andcontracts with BCBS of ND.• BCBS of HI has a remote provider contractwith the lab company for specimens drawnin HI.• BCBS of NE has a remote providercontract with the lab company forspecimens drawn in Nebraska (NE).North DakotaNebraska• BCBS of AL member has a specimendrawn in HI.• Specimen sent to the regional labin NE for analysis.HawaiiA presentation of the Blue Cross and Blue Shield Association. All rights reserved.AL member77

Remote Ancillary Providers: Scenario FourNote: The following scenarios are applicable to ancillary providers(Lab, DME/HME and Specialty Pharmacy).• Lab provider is located in ND andcontracts with BCBS of ND.• BCBS of HI has a remote provider contractwith the lab company for specimens drawnin HI.• BCBS of NE has a remote providercontract with the lab company forspecimens drawn in Nebraska (NE).HostPlanNorth DakotaNebraska• BCBS of AL member has a specimendrawn in HI.• Specimen sent to the regional labin NE for analysis.• Lab provider files a claim for the drawand the analysis to BCBS of HI. It is aBlueCard in-network claim.A presentation of the Blue Cross and Blue Shield Association. All rights reserved.AL memberHawaii78

Remote Ancillary Providers: Scenario FiveNote: The following scenarios are applicable to ancillary providers(Lab, DME/HME and Specialty Pharmacy).• Lab provider is located in ND and does notcontract with BCBS of ND.North DakotaA presentation of the Blue Cross and Blue Shield Association. All rights reserved.79

Remote Ancillary Providers: Scenario FiveNote: The following scenarios are applicable to ancillary providers(Lab, DME/HME and Specialty Pharmacy).• Lab provider is located in ND and does notcontract with BCBS of ND.North Dakota• BCBS of HI does not have a remote providercontract with this provider for specimensdrawn in HI.HawaiiA presentation of the Blue Cross and Blue Shield Association. All rights reserved.80

Remote Ancillary Providers: Scenario FiveNote: The following scenarios are applicable to ancillary providers(Lab, DME/HME and Specialty Pharmacy).• Lab provider is located in ND and does notcontract with BCBS of ND.• BCBS of HI does not have a remote providercontract with this provider for specimensdrawn in HI.• BCBS of NE has a remote provider contractwith this lab company.North DakotaNebraskaHawaiiA presentation of the Blue Cross and Blue Shield Association. All rights reserved.81

Remote Ancillary Providers: Scenario FiveNote: The following scenarios are applicable to ancillary providers(Lab, DME/HME and Specialty Pharmacy).• Lab provider is located in ND and does notcontract with BCBS of ND.• BCBS of HI does not have a remote providercontract with this provider for specimensdrawn in HI.• BCBS of NE has a remote provider contractwith this lab company.North DakotaNebraska• BCBS of AL member has a specimendrawn in HI.HawaiiA presentation of the Blue Cross and Blue Shield Association. All rights reserved.AL member82

Remote Ancillary Providers: Scenario FiveNote: The following scenarios are applicable to ancillary providers(Lab, DME/HME and Specialty Pharmacy).• Lab provider is located in ND and does notcontract with BCBS of ND.• BCBS of HI does not have a remote providercontract with this provider for specimensdrawn in HI.• BCBS of NE has a remote provider contractwith this lab company.North DakotaNebraska• BCBS of AL member has a specimendrawn in HI.• Specimen sent to the regional lab in NEfor analysis.HawaiiA presentation of the Blue Cross and Blue Shield Association. All rights reserved.AL member83

Remote Ancillary Providers: Scenario FiveNote: The following scenarios are applicable to ancillary providers(Lab, DME/HME and Specialty Pharmacy).• Lab provider is located in ND and does notcontract with BCBS of ND.• BCBS of HI does not have a remote providercontract with this provider for specimensdrawn in HI.• BCBS of NE has a remote provider contractwith this lab company.• BCBS of AL member has a specimendrawn in the BCBS of HI.HostPlanNorth DakotaNebraska• Specimen sent to the regional lab in NEfor analysis.Hawaii• Lab provider files a claim for the draw andthe analysis to BCBS of HI. It is a BlueCardout-of-network claim.A presentation of the Blue Cross and Blue Shield Association. All rights reserved.AL member84

Remote Ancillary Providers: Scenario SixNote: The following scenarios are applicable to ancillary providers(Lab, DME/HME and Specialty Pharmacy).• Lab provider is located in ND andcontracts with BCBS of ND.North DakotaA presentation of the Blue Cross and Blue Shield Association. All rights reserved.85

Remote Ancillary Providers: Scenario SixNote: The following scenarios are applicable to ancillary providers(Lab, DME/HME and Specialty Pharmacy).• Lab provider is located in ND andcontracts with BCBS of ND.CaliforniaNorth Dakota• Both California Plans: Anthem BlueCross and Blue Shield of Californiahave remote provider contracts withthis provider.andA presentation of the Blue Cross and Blue Shield Association. All rights reserved.86

Remote Ancillary Providers: Scenario 6Note: The following scenarios are applicable to ancillary providers(Lab, DME/HME and Specialty Pharmacy).• Lab provider is located in ND andcontracts with BCBS of ND.CaliforniaNorth Dakota• Both California Plans: Anthem BlueCross and Blue Shield of Californiahave remote provider contracts withthis provider.• BCBS of AL member has a specimendrawn in California (overlapping servicearea).andAL memberA presentation of the Blue Cross and Blue Shield Association. All rights reserved.87

Remote Ancillary Providers: Scenario SixNote: The following scenarios are applicable to ancillary providers(Lab, DME/HME and Specialty Pharmacy).• Lab provider is located in ND andcontracts with BCBS of ND.CaliforniaNorth Dakota• Both California Plans: Anthem BlueCross and Blue Shield of Californiahave remote provider contracts withthis provider.HostPlan• BCBS of AL member has a specimendrawn in California (overlapping servicearea).and• Lab provider files a claim to either BluePlan in California. It is a BlueCard,in-network claim.AL memberA presentation of the Blue Cross and Blue Shield Association. All rights reserved.88

Remote Ancillary Providers: Scenario SevenNote: The following scenarios are applicable to ancillary providers(Lab, DME/HME and Specialty Pharmacy).• Lab provider is located in ND andcontracts with BCBS of ND.North DakotaA presentation of the Blue Cross and Blue Shield Association. All rights reserved.89

Remote Ancillary Providers: Scenario SevenNote: The following scenarios are applicable to ancillary providers(Lab, DME/HME and Specialty Pharmacy).• Lab provider is located in ND andcontracts with BCBS of ND.CaliforniaNorth Dakota• Anthem Blue Cross (CA) has a remoteprovider contract with this provider. BSof CA does not have a remote providercontract with this provider.andA presentation of the Blue Cross and Blue Shield Association. All rights reserved.90

Remote Ancillary Providers: Scenario SevenNote: The following scenarios are applicable to ancillary providers(Lab, DME/HME and Specialty Pharmacy).• Lab provider is located in ND andcontracts with BCBS of ND.CaliforniaNorth Dakota• Anthem Blue Cross (CA) has a remoteprovider contract with this provider. BSof CA does not have a remote providercontract with this provider.• BCBS of AL member has a specimendrawn in California (overlappingservice area).andAL memberA presentation of the Blue Cross and Blue Shield Association. All rights reserved.91

Remote Ancillary Providers: Scenario SevenNote: The following scenarios are applicable to ancillary providers(Lab, DME/HME and Specialty Pharmacy).• Lab provider is located in ND andcontracts with BCBS of ND.CaliforniaNorth Dakota• Anthem Blue Cross (CA) has a remoteprovider contract with this provider. BSof CA does not have a remote providercontract with this provider.• BCBS of AL member has a specimendrawn in California (overlappingservice area).HostPlan• Lab provider files a claim to AnthemBC (CA). It is a BlueCard in-networkclaim.andAL memberA presentation of the Blue Cross and Blue Shield Association. All rights reserved.92

Air Ambulance Claim Filing: Example• An air ambulancecompany located inNebraska picked up anIllinois member inWyoming andtransported the memberto Colorado.• The provider should filethe claim to Blue Crossand Blue Shield ofNebraska.COclaimNEA presentation of the Blue Cross and Blue Shield Association. All rights reserved.93

Dental Claims• Dental claims are excluded fromBlueCard, except for:– Dental-related services coveredunder the member’s medical benefits.• Member ID cards for standalone dentaldo not display an alpha prefix.• Follow claim filing instructions on theback of the member ID card.A presentation of the Blue Cross and Blue Shield Association. All rights reserved.94

Pharmacy and Vision Claims• Pharmacy and vision benefits can beadministered by the member’s Blue Plan or bythe intermediary (e.g., Davis Vision, Caremark)• Claims for prescription drug benefits and visionbenefits delivered through an intermediary arefiled with the intermediary.• Claims for prescription drug benefits and visionbenefits that are not delivered through anintermediary should be filed to BlueShield ofNortheastern New York.– This includes claims for medical vision servicescovered under the member’s medical benefits.A presentation of the Blue Cross and Blue Shield Association. All rights reserved.95

Telemedicine Claims• Telemedicine is the transmitting and receiving of patient’s clinical data viaelectronic communication for the purpose of analysis and interpretation.• Telemedicine includes, but is not limitedto, telephonic services, internet servicesand radiology.• Telemedicine claims are filed basedon where the services are rendered,which is with the Plan in whose servicearea the provider is physically located.A presentation of the Blue Cross and Blue Shield Association. All rights reserved.96