BlueCard Program FAQs
Q. What is the BlueCard Program?
The BlueCard Program links participating health care providers and the independent Blue Cross and Blue Shield Plans across the country and abroad with a single electronic network for claims processing and reimbursement. The program allows participating providers in every state to submit almost all types of claims for out-of-state members to their local Blue Cross and Blue Shield Plan. This program eliminates your need to track money due from multiple Blue Cross and Blue Shield Plans. We process your reimbursement and provide you an Explanation of Payment (EOP).
Q. Can providers who do not participate with Horizon Blue Cross Blue Shield of New Jersey submit claims?
New Jersey providers that do not participate with Horizon BCBSNJ may also send their claims to us to be submitted to the appropriate plan for processing; however, these providers may not receive reimbursement from their local plan and will still be required to bill the patient.
Q. What are the advantages of the BlueCard Program?
The BlueCard Program eliminates the need for you to deal with multiple Blue Cross and/or Blue Shield Plans. Horizon BCBSNJ is your single point of contact for claims, payments, adjustments, service and claims-related inquiries.
Q. How do I identify BlueCard members?
BlueCard members are easily identified by their ID cards. Ask to see the member’s ID card at each visit and share this information with your billing staff. Review these ID cards for the telephone number of the member’s “home” Plan, claim filing addresses or for other instructions.
There are three ID card elements you should look for to identify a BlueCard member:
- Plan logo:The presence of another Blue Cross and/or Blue Shield’s Plan logo on the member’s ID card is the first visual indicator that a member may be eligible for BlueCard benefits.
- Alpha prefix:The alpha prefix on the member’s ID card is the key element used to identify the Plan to which the member belongs and to correctly route claims. It is critical to confirm membership, eligibility and coverage. If there is no prefix on a member’s ID card, that member is not eligible for benefits through the BlueCard Program.
- Suitcase logo:Members whose ID cards display the PPO in the suitcase logo are enrolled in PPO (Preferred Provider Organization) products. Benefits are delivered through the BlueCard Program. Members traveling or living outside their Plan’s service area receive PPO-level benefits when they need services from participating physicians and other health care professionals. Members whose ID cards display the blank suitcase logo are enrolled in a product other than PPO. These members are also eligible for BlueCard processing.
Members whose ID cards do not display a suitcase logo are excluded from receiving benefits through the BlueCard Program.
Q. How do I submit BlueCard claims?
Offices that participate with Horizon BCBSNJ should submit BlueCard claims electronically with other Horizon BCBSNJ claims or send paper claims to:
PO Box 1301 Neptune, NJ 07754-1301
If you participate with another Plan, please submit claims directly to that Plan for processing.
Q. How are BlueCard claims processed?
Once we receive your claims, we will electronically route them to the out-of-state Blue Cross Blue Shield Plan that will process the claim according to each member's contract. They will transmit the claim information to us, which will be included on your Provider Check Voucher. Please make sure that you are submitting the claims with the appropriate alpha prefixes.
Q. How is the BlueCard Program administered?
Blue Cross and Blue Shield Association providers serve nearly 90 million members nationwide, including almost 20 million national account members. We understand the importance of ensuring easy administration for you, and we want your patients to have a positive experience with each visit.
As a result, we are committed to meeting your needs and expectations by giving you a single point of contact through your local Plan for claims, customer service and provider education-related inquiries.
Q. Are there additional provider resources for the BlueCard Program?
If you have any questions about the BlueCard Program or filing claims for out-of-area patients, call our Dedicated BlueCard Unit at 1-888-435-4383.
Additional educational material for our BlueCard Program is available once you register or sign in to Provider Online Services.
Q. What is the difference between the Home Plan and the Host Plan?
The Home Plan is the Blue Cross and/or Blue Shield Plan through which the member is enrolled. The Host Plan is the Blue Cross and/or Blue Shield Plan in the area where services are rendered.
Q. Whom do I contact for information on a BlueCard claim?
For claims and claims-related questions, Horizon BCBSNJ’s Dedicated BlueCard Physician Unit can be reached at 1-888-435-4383. This Unit is your source for all claims and claims-related questions.
Q. What is the BlueCard medical records process?
The BlueCard Program links all Blue Cross and/or Blue Shield (BCBS) Plans allowing for streamlined claims adjudication. Part of the adjudication process often includes requests from other BCBS Plans for additional information and/or medical records to assist in the review and finalization process. BCBS Plans have a formal process that requires those plans to request that information through us. Then, we send one of the following form letters to our providers for the information that is needed. The letter includes a direct point of contact at Horizon BCBSNJ to expedite the process on our end.
Once we have sent out the request, we rely on you, our providers, to expedite the information requested so that the claim processing can be completed. Please assist us in meeting your timeliness expectations by responding to our request and sending the noted information back to the address and individual listed.
Q. Are there BlueCard exclusions?
The following services cannot be submitted through the BlueCard Program and must be submitted directly to the member's plan:
- Stand-alone dental coverage.
Stand-alone prescription drug coverage.
If you currently contract with another BlueCross and BlueShield Plan and render services to a member for that plan, those claims should be sent directly to that plan.
Q. Whom do I contact for pre-certification of out-of-state services?
The member is responsible for securing prior authorization and pre-certification, when required. You may do this on behalf of the member by calling 1-800-676-BLUE (2583).
Q. Are prefixes required when submitting BlueCard claims?
Alpha prefixes are required when submitting BlueCard claims. The alpha prefix on the member’s ID card is the key element used to identify the Plan to which the member belongs and to correctly route claims. If there is no prefix on a member’s ID card, that member may not be eligible for benefits through the BlueCard Program. Check the patient’s ID card and call the appropriate Blue Cross and Blue Shield Plan to obtain the alpha prefix or to obtain claim submission instructions.
Q. Why do you pend an entire claim when there is a problem with only one item?
For audit purposes, Horizon BCBSNJ must either accept or reject a claim as originally submitted.
Additionally, one item can impact the payment of the entire claim. For example, when a claim is submitted for surgery, and the physician or other health care professional bills with an invalid surgical procedure code and there are multiple surgical procedure codes listed on the claim, the invalid procedure code may impact payment. Therefore, the entire claim has to be pended in order to process it correctly.
Q. Where should claims be sent for prefix NJX?
NJX is the prefix for the New Jersey State Health Benefits Program's NJ DIRECT plan. NJ DIRECT members have BlueCard benefits when receiving services outside of New Jersey. As a Horizon BCBSNJ participating physician or other health care professional, when rendering services in New Jersey to a NJ DIRECT member, file claims with Horizon BCBSNJ as instructed on the member's ID card.
Q. Should claims for members with coverage from Empire Blue Cross Blue Shield be submitted directly to Empire BCBS, or should I submit these claims through BlueCard?
If you are treating an Empire BCBS member and you contract with Horizon BCBSNJ and Empire BCBS, file the member's claim directly with Empire BCBS. If you are treating an Empire BCBS member and services are rendered in New Jersey and you contract only with Horizon BCBSNJ, file the member's claim with Horizon BCBSNJ for BlueCard claim processing.
Q. We currently participate with Independence Blue Cross, AmeriHealth and Keystone. Can we submit claims for all three plans through BlueCard?
If you are treating an Independence Blue Cross member and you contract with Horizon BCBSNJ and Independence Blue Cross, file the member's claim directly with Independence Blue Cross. If you are treating an Independence Blue Cross member and services are rendered in New Jersey and you contract only with Horizon BCBSNJ, file the member's claim with Horizon BCBSNJ for BlueCard claim processing. For AmeriHealth and Keystone, refer to the member's ID card for the appropriate claims filing instructions.
Q. Is it possible to receive a list of phone numbers for the different plans to pre-authorize radiology services?
Unfortunately, at this time, an all-inclusive list of radiology authorization contact numbers is not available. We ask that you call 1-800-676-BLUE (2583) for specific member eligibility and benefit information. A knowledgeable representative will assist you.
Q. We are having problems with BlueCard as a secondary payer to Medicare. When claims are forwarded electronically to BlueCard as secondary, they are sent to the Home Plan, and we cannot get assistance from BlueCard with payment issues.
Call our Dedicated BlueCard Physician Unit at 1-888-435-4383. A representative will assist you with any claims-related questions, including Medicare issues. Our experienced BlueCard representatives will work directly with the member’s Home Plan, on your behalf, until your questions are resolved.
For additional information on the BlueCard Program, visit the Blue Cross and Blue Shield Association website at www.BCBS.comwww.BCBS.com opens a dialog window.