December 29, 2016

Billing Requirements for Ancillary Claim Services

The Blue Cross Blue Shield Association has required that all Blues plans comply with the following billing mandates for durable medical equipment, independent clinical lab and specialty pharmacy claims.  These guidelines will be implemented by BlueCross BlueShield of Western New York and BlueShield of Northeastern New York on August 20th 2012 and are intended to help standardize claim filing procedures, regardless of your location.

WHAT YOU NEED TO KNOW:

  • Federal Employee Program (FEP) members are excluded from this mandate
  • If you have a contract with the local Blue plan, the claim will be considered a participating claim. If you do not have a contract with the local plan, it will be considered a non-participating claim.
  • For additional BlueCard billing information, go to www.bcbswny.com or www.bsneny.com.
  • Prior to rendering any services, always verify member eligibility and benefits through www.wnyhealthenet.org or by calling BlueCard EligibilitySM at 1-800-676-BLUE (2583).

WHAT YOU NEED TO DO:

  • DME
    • File the claim with the plan located in the service area in which the equipment was shipped to, or where it was purchased in a retail store.
    • The referring provider and referring provider NPI are required on all claims.

      EDI editing will check the following:
      If the procedure code (2400 SV101-2) is classified as DME, and the place of service (2300 CLM05-1) equals, 12, 04, 09, 13, 14, 34, or 55, then the first 5 positions of the patient zip code (2010CA N403), if present, or the insured zip code (2010BA N403) must be on the Highmark Western and Northeastern New York ZIP Code List, else reject.
      A7:116 / A7:126:QC
      A7:116 / A7:126:IL

      If the Procedure Code (2400 SV101-2) is classified as DME, and the Place of Service (2300 CLM05-1) DOES NOT equal 11, 12, 04, 09, 13, 14, 34, 20 or 55, then the first 5 positions of the Servicing Zip (2310C N403), if present, or the Billing Provider Zip (2010AA N403) must be on the Highmark Western and Northeastern New York ZIP Code List, else reject.
      A7:116 / A7:126:77
      A7:116 / A7:126:85

  • LAB
    • File the claim with the plan located in the service area where the referring physician is located.
    • The referring provider NPI is required on all claims.

      EDI editing will check the following:
      If Place of Service (2300 CLM05-3) equals 81 (Independent Clinical Lab), then a Referring Physician NPI (2310A NM109 where NM109=XX) is required, else reject.
      A6:562:DN

      If Referring Physician NPI is present on the Highmark Western and Northeastern New York provider file, then the Referring Physician Zip Code when checked against the Highmark Western and Northeastern New York provider file, must be on the Highmark Western and Northeastern New York ZIP Code List, else reject.
      A7:116 / A7:126:DN

  • SPECIALTY PHARMACY
    • File the claim with the plan located in the service area where the referring physician is located.
    • The referring provider and referring provider NPI are required on all claims.

      EDI editing will check the following:
      If Taxonomy Code 3336S0011X is present, classified as Specialty Pharmacy, then a Referring Physician NPI in the 2310A NM109 (where the 2310A NM101 = DN and the NM108 = XX) is required, else reject.
      A6:562:DN

      If Referring Physician NPI is present on the Highmark Western and Northeastern New York Provider file, then the Referring Physician Zip Code when checked against the Highmark Western and Northeastern New York Provider file, must be on the Highmark Western and Northeastern New York ZIP Code List, else reject.
      A7:116: / A7:126:DN