Provider Manual. 1 P a g e V14 E D R C - 175

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1 Provider Manual V14 1 P a g e

2 BlueCard Summary and Best Practices 2 P a g e

3 BlueCard Process (Out of State Home Plans) BlueCard BlueCard is a program that allows Blue Cross Blue Shield patients to obtain health care nationally. Under the BlueCard program, when a Blue Cross patient needs care outside their residence state, that care is arranged through another Blue Cross plan (the Host Plan ). For example, a patient residing in Ohio that is covered through an Ohio Blue Cross Plan (the Home Plan ) can receive care in the State of Florida through Florida Blue. BlueCard Process The eligibility and benefits verification and authorization process for BlueCard patients is different from the process applicable to your other patients. For BlueCard patients, you are required to verify eligibility and benefits with the patient s Home Plan (not the Host Plan). You can verify eligibility and benefits by: 1) Contacting the patient s Home Plan directly. The patient s Home Plan contact information can be found on the patient s insurance identification card; or 2) Calling You will be asked to provide the alpha prefix on the insurance card, and then the representative will transfer you to the appropriate Home Plan. You can also verify eligibility and benefits electronically at When submitting the Subscriber ID, include the complete ID with alpha prefix. Do not include spaces or hyphens. If the Subscriber ID does not have an alpha prefix, eligibility and benefits cannot be verified electronically. Please note that Home Plan hours can vary, and some requests may take longer depending on the Home Plan s hours of operation. 3 P a g e

4 You are also required to obtain authorizations or pre-certifications from the Home Plan (not CareCentrix) when authorization or pre-certification is required for the service. When you receive a referral relating to a BlueCard patient directly from the referral source: 1. Determine from the Home Plan if authorization is required 2. If so, obtain authorization for the requested services from the Home Plan (not CareCentrix). Please note that the Home Plan may require you to submit clinical documentation to substantiate the medical necessity of the services requested. When CareCentrix receives a BlueCard referral from a primary referral source, CareCentrix will staff with a Provider. Upon the Provider s acceptance of the referral, CareCentrix will issue a Service Request Form (SRF) to the servicing Provider. This form will include: Patient s name and demographics Subscriber ID number Services Requested to include the HCPCS/modifier combination and description dates will reflect same start and end date and 0 units will be displayed. Instructions on contacting the Home Plan for eligibility and benefits verification and authorization. The Service Request Form will not include an authorization number because the Provider must obtain any required authorizations from the Home Plan. If you experience any delay when working with the Home Plan or cannot meet the prescribed start of care for any reason, you must notify CareCentrix, the treating physician and the primary referral source of the delay. 4 P a g e

5 If you are unable to obtain a precertification from the Home Plan in time to meet the start of care, please call CareCentrix immediately at If you must turn back a BlueCard case that was previously accepted from CareCentrix, you must contact CareCentrix before the start of care date and within at least 2 business hours after you become aware that you are unable to service the patient. Claims associated with BlueCard patients must be submitted to CareCentrix. CareCentrix will pass BlueCard clean claims to the Host Plan at which time compliance with authorization requirements will be reviewed. Claims for services for BlueCard patients that did not follow the Home Plan s authorization requirements may be denied in whole or in part, and such denied claims may not be billed to the patient. For more specific information on the BlueCard process, please refer to the BlueCard Process training documents posted on the CareCentrix Provider Portal. 5 P a g e