Empire BlueCross Lab, DME, and Specialty Pharmacy Blue Claims
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1 Medicare Advantage Provider s Frequently Asked Questions Empire BlueCross Lab, DME, and Specialty Pharmacy Blue Claims Generally, as a healthcare provider you should file claims for your Blue Cross and Blue Shield (BC/BS) patients to the local Blue Plan. However, there are circumstances when claims filing directions will differ based on the type of ancillary provider. To that point, effective October 14, 2012, Empire Blue Cross (Empire) implemented claim filing requirements, based on ancillary provider type. Q. Where should I file the claim? A. Please see below based on what type of claim you are filing; Independent Clinical Laboratory (Lab) --The claim must be filed to the BC/BS Plan where the specimen was drawn. (DME) --The claim must be filed to the BC/BS Plan where the equipment was delivered to or rented/purchased at a retail store. Specialty Pharmacy --The claim must be filed to the BC/BS Plan where the ordering/referring physician is located. Q. When did this go into effect? A. This Blue Cross and Blue Shield Association policy went into effect on 10/14/12. Q. Does this apply to non-contracting providers? A. The ancillary claim filing rules apply regardless of the provider s contracting status with the Blue Plan where the claim is filed. If non-participating with the Plan, the provider must still file the claim to the Plan where the specimen is drawn; DME is rented, purchased or delivered; or the physician ordering the specialty Rx is located. Q. How can I verify Member Eligibility and Benefits? A. You can check by calling the number on the back of the member s ID card or by calling BLUE. Q. How best can I file an ancillary claim to avoid the chance of a rejected claim? A. In addition to the CMS required fields to be filed on a claim, Empire has created the chart on the following page to help insure all necessary claim fields are included.
2 Independent Clinical Laboratory Types of Service include Blood or urine specimens (D/HME) delivered to patient. Loop 2310A (claim level) on the 837 Patient s Address: Field 5 on CMS 1500 Loop 2010CA on the 837 Submission. Claim specimen was drawn.* Where the specimen was drawn will be determined by the address associated with the referring/ordering provider s NPI. equipment was delivered. Blood is drawn* in lab or office setting located in Plan X service Blood analysis is done in Plan Y service *Claims for the analysis of a lab must be filed to the Plan in whose service area the specimen was drawn. Wheelchair is rented/purchased from an and delivered to an address in Plan Y service Oxygen is rented from an and is delivered to the patient s address in Plan Y service (D/HME) rented/purchased at a retail location. Claim Service Facility Location Information: Field 32 on CMS 1500 Health Insurance Loop 2310C (claim level) on equipment was rented/purchased in a retail store. Crutches are purchased at a retail store located in Plan Y service
3 Specialty Pharmacy Types of Service: Non-routine, biological therapeutics ordered by a healthcare professional as a covered medical benefit. Loop 2310A (claim level) on ordering/referring physician is located. The ordering/referring physician location is determined by the address associated with the provider NPI. Patient is seen by a physician in Plan X service area who orders a specialty pharmacy injectable for this patient. Patient will receive the injections in Plan Y service area where the member lives for 6 months of the year. Q. Where can I go to check the status of my claim(s)? A. For the ancillary types listed above, to check on the status of a claim, you can access Availity to obtain information on any Empire Plan and many other Blue Plans. For more information or to register, go to Q. What can I do if I have additional questions? A. If you have additional questions about filing ancillary claims please call the number on the back of the member s ID card. Y0071_14_19500_I_004 Services provided by Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
4 Medicare Advantage Outreach and Education Bulletin Empire BlueCross BlueShield Lab, DME, and Specialty Pharmacy Blue Claims Generally, as a healthcare provider you should file claims for your Blue Cross and Blue Shield (BC/BS) patients to the local Blue Plan. However, there are circumstances when claims filing directions will differ based on the type of ancillary provider. To that point, effective October 14, 2012, Empire BlueCross BlueShield(Empire) will implemented claim filing requirements, based on ancillary provider type. Q. Where should I file the claim? A. Please see below based on what type of claim you are filing; Independent Clinical Laboratory (Lab) --The claim must be filed to the BC/BS Plan where the specimen was drawn. (DME) --The claim must be filed to the BC/BS Plan where the equipment was delivered to or rented/purchased at a retail store. Specialty Pharmacy --The claim must be filed to the BC/BS Plan where the ordering/referring physician is located. Q. When did this go into effect? A. This Blue Cross and Blue Shield Association policy went into effect on 10/14/12. Q. Does this apply to non-contracting providers? A. The ancillary claim filing rules apply regardless of the provider s contracting status with the Blue Plan where the claim is filed. If non-participating with the Plan, the provider must still file the claim to the Plan where the specimen is drawn; DME is rented, purchased or delivered; or the physician ordering the specialty Rx is located. Q. How can I verify Member Eligibility and Benefits? A. You can check by calling the number on the back of the member s ID card or by calling BLUE. Q. How best can I file an ancillary claim to avoid the chance of a rejected claim? A. In addition to the CMS required fields to be filed on a claim, Empire has created the chart on the following page to help insure all necessary claim fields are included.
5 Independent Clinical Laboratory Types of Service include Blood or urine specimens (D/HME) delivered to patient. Loop 2310A (claim level) on the 837 Patient s Address: Field 5 on CMS 1500 Loop 2010CA on the 837 Submission. Claim specimen was drawn.* Where the specimen was drawn will be determined by the address associated with the referring/ordering provider s NPI. equipment was delivered. Blood is drawn* in lab or office setting located in Plan X service Blood analysis is done in Plan Y service *Claims for the analysis of a lab must be filed to the Plan in whose service area the specimen was drawn. Wheelchair is rented/purchased from an and delivered to an address in Plan Y service Oxygen is rented from an and is delivered to the patient s address in Plan Y service (D/HME) rented/purchased at a retail location. Claim Service Facility Location Information: Field 32 on CMS 1500 Health Insurance Loop 2310C (claim level) on equipment was rented/purchased in a retail store. Crutches are purchased at a retail store located in Plan Y service
6 Specialty Pharmacy Types of Service: Non-routine, biological therapeutics ordered by a healthcare professional as a covered medical benefit. Loop 2310A (claim level) on ordering/referring physician is located. The ordering/referring physician location is determined by the address associated with the provider NPI. Patient is seen by a physician in Plan X service area who orders a specialty pharmacy injectable for this patient. Patient will receive the injections in Plan Y service area where the member lives for 6 months of the year. Q. Where can I go to check the status of my claim(s)? A. For the ancillary types listed above, to check on the status of a claim, you can access Availity to obtain information on any Empire Plan and many other Blue Plans. For more information or to register, go to Q. What can I do if I have additional questions? A. If you have additional questions about filing ancillary claims please call the number on the back of the member s ID card. Y0071_14_19500_I_005 Services provided by Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
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