The BlueCard® Program

The BlueCard® Program links you and independent Blue Cross and/or Blue Shield Plans, across the country and abroad, with a single electronic network for claims processing and reimbursement.

The BlueCard® program eliminates the need to deal with multiple Blue Plans. Horizon is your one point of contact for claims or claims-related questions.

The exception to this is if your office participates directly with the plan in which a BlueCard® member is enrolled. If you participate with the other Blue Plan, please submit claims directly to that other Blue Plan.

The program allows you to submit almost all types of claims for out-of-state members directly to us, your local Blue Plan. We process your reimbursement and provide you with an Explanation of Payment (EOP).

Please treat BlueCard® members the same as you would a local Horizon member. Doing so will increase your patients’ satisfaction and improve their overall BlueCard® experience. Billing charges in excess of the allowance is not permitted.

For additional information, view our page or the BCBS Association BlueCard® program page.

IDENTIFYING BLUECARD® MEMBERS

The key to identifying BlueCard® members is their ID cards. There are three ID card elements you should look for to identify a BlueCard® member:

Blue Plan Logo

The presence of another Blue Cross and/or Blue Shield Plan’s logo on the member’s ID card means a member may be eligible for BlueCard® benefits.

Member ID Card Prefix

The prefix on the member’s ID card can identify the Blue Plan to which the member belongs and to route claims correctly. Please confirm membership, eligibility and coverage.

If there is no prefix on a member’s ID card, review the member’s ID card for the phone number of the member’s Blue Plan or for other instructions.

Suitcase Logo

The suitcase logos are unique identifiers for BlueCard® members.

• Members whose ID cards display the PPO-in-a-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, other health care professionals, hospitals and other facilities.

• Members whose ID cards display the PPO B-in-a-suitcase logo are enrolled in an exchange PPO product from a Blue Plan. The member has access to the exchange PPO network, referred to as BlueCard® PPO Basic. BlueCard® plans that use our Horizon Managed Care Network are also known as Alternate Network BlueCard® (AltNet) plans.

• Members whose ID cards display the empty suitcase logo are enrolled in a product other than PPO, for example, Traditional, POS or HMO. These members are also eligible for BlueCard® processing. However, benefits for services obtained outside the member’s local service area may be limited to those related to a medical emergency. Please verify BlueCard® benefits for members whose ID card display the empty suitcase logo.

Members whose ID cards do not display a suitcase logo are excluded from receiving benefits through the BlueCard® program. Be sure to review the member’s ID card for phone numbers and claim filing addresses.

BLUECARD® ID CARDS

All Blue Cross and/or Blue Shield Plans are independent licensees of the Blue Cross Blue Shield Association (BCBSA) and are required to follow specific ID card standards. ID cards must contain the following elements on the front of the card:

• Member’s name.
• ID number.
• Group number, if applicable.
• Blue Cross and/or Blue Shield Plan code, a numeric value identifying each Blue Plan. In New Jersey, our codes are 280 and 780.
• Blue Cross and/or Blue Shield symbols. Some Plans are only a Blue Cross or a Blue Shield Plan. Their ID cards may only show one symbol rather than both the Cross and Shield. The BCBSA has licensed them in a state or given geographic area to offer only certain products or services under the Blue Cross or Blue Shield brand name and symbol.
• Blue Cross and/or Blue Shield Plan name, which may be a Plan’s legal name or it may be a trade name. Our ID cards are issued with the Horizon name.

PARTICIPATING PHYSICIAN INFORMATION

To obtain information about participating physicians and other health care professionals in another BCBS Plan service area, members may call BlueCard® Access at 1-800-810-BLUE (2583).

BLUECARD® ELIGIBILITY AND BENEFITS

You can obtain eligibility and benefits information for your BlueCard® patients by phone or electronically. Remember to have the member’s ID card information handy.

Obtaining Information by Phone

You can call BlueCard® Eligibility at 1-800-676-BLUE (2583). After providing the prefix from the member’s ID card, you’ll be connected to the Customer Service team at the member’s Blue Plan.

If the member’s ID card does not include a prefix, please call the phone number on the ID card.

Obtaining Information Electronically

You may submit a HIPAA 270 transaction to Horizon to request the information you need. Most BlueCard® electronic inquiries received weekdays, during regular business hours, are answered within 48 hours.

PRIOR AUTHORIZATION AND UTILIZATION MANAGEMENT

Your patients who are enrolled through other Blue Cross and/or Blue Shield Plans and who have BlueCard® benefits, are responsible for obtaining prior authorizations.

All hospital admission and/or concurrent reviews and discharge planning are completed by the patient’s Blue Plan.

You may choose to contact the Blue Cross and/or Blue Shield Plan in which your patient is enrolled to obtain the prior authorization or pre-authorization. Refer to your patient’s ID card for phone number information or call 1-800-664-BLUE (2583).

Inpatient Prior Authorization/Precertification

Network facilities must obtain prior authorization/precertification for inpatient facility services for BlueCard® patients. This requirement only applies to inpatient facility services.

Prior authorization, precertification, admission and/or concurrent reviews and discharge planning must be completed by the Blue Cross and/or Blue Shield Plan through which the patient is enrolled.

To obtain prior authorization/precertification for your patients enrolled in BlueCard® plans, call BlueCard® Eligibility at 1-800-664-BLUE (2583) or the appropriate phone number listed on the BlueCard® member’s ID card, or submit an electronic 278 transaction.

If prior authorization/precertification is required and not obtained for inpatient facility services, the facility will be financially responsible and the member will be held harmless.

Note: The responsibilities and obligations outlined in this section are applicable to out-of-state Blue Cross and/or Blue Shield members.

SUBMITTING BLUECARD® CLAIMS

Submit BlueCard® claims electronically with other Horizon claims or send paper claims to:

• Horizon BlueCard® Claims
  PO Box 1301
  Neptune, NJ 07754-1301

Include the member’s complete ID number when you submit the claim. Claims with incorrect or missing prefixes and member ID numbers delay claims processing.

If the patient’s ID card does not include a prefix, check for a phone number on the card. Call the appropriate Blue Cross and/or Blue Shield Plan for claim submission instructions.

Do not send duplicate claims. Check a claim’s status through our Interactive Voice Response (IVR) system, NaviNet or through an electronic transaction before you resubmit a claim.

DME Claim Submissions

Claims for DME services must be sent to the Blue Plan in the state in which the equipment was delivered or purchased. The claim will process according to the DME provider’s contractual relationship with the Blue Plan.

For example, if the equipment is purchased from a New Jersey DME retail store or delivered to a New Jersey address, that claim must be sent to Horizon and will process according to the DME provider’s contractual relationship with Horizon.

However, if the equipment is purchased by or delivered to a Horizon member in Pennsylvania, the claim must be sent to the Pennsylvania Blue Plan and will process based on the DME provider’s contractual relationship with that Pennsylvania Blue Plan and consistent with the member’s Home Plan benefits.

BLUECARD® CLAIMS PROCESSING

We will electronically route the claim information to the other Blue Cross and/or Blue Shield Plan that will process the claim and approve reimbursement. The other plan will transmit the approval to us and we will issue reimbursement and an EOP to you.

BEHAVIORAL HEALTH AND SUBSTANCE USE DISORDER CLAIMS AND INQUIRIES

All behavioral health and substance use disorder claim submissions and inquiries for your BlueCard® patients (those enrolled in another state’s Blue Cross and/or Blue Shield Plan) must be handled through the BlueCard® program.

Claim Submissions

Claims should be submitted electronically using NaviNet or through your vendor using Payer ID 22099. The Braven Health Payer ID is 84367.

If you have to mail your claims, use the following address:

• Horizon BlueCard® Claims
  PO Box 1301
  Neptune, NJ 07754-1301

Be sure to include the member’s complete ID number when you submit claims. Incorrect or missing prefixes and member ID numbers delay claims processing.

If your office participates directly with another Blue Cross and/or Blue Shield Plan, send claims for those enrolled patients directly to that Plan.

Claim Inquiries

Call Horizon’s BlueCard® Unit at 1-888-435-4383 or visit NaviNet.net.

ELIGIBILITY/ENROLLMENT INQUIRIES

Call BlueCard® Eligibility at 1-800-676-BLUE (2583) or visit NaviNet.net.

This claims submission information pertains only to your patients enrolled through an out-of-state Blue Cross and/or Blue Shield Plan.

BLUECARD® CLAIM SUBMISSIONS HELPFUL HINTS

Be sure to include the prefix and the complete ID number on all claim submissions. Incorrect or incomplete information may delay claims processing or cause the claim to deny, since we will be unable to identify the member.

Always include appropriate ICD-10, revenue and CPT-4 codes.

Ensure that section 1A of the CMS 1500 form is completed by entering either the requested information or the word Same, as appropriate, in boxes 4 and 7 for all BlueCard® paper claim submissions.

BLUECARD® EXCLUSIONS

BlueCard® applies to most claims; however, the following types of claims currently are excluded from the program:

• Coordination of Benefits situations when the Blue Cross and/or Blue Shield Plan is not the primary carrier
• Workers’ compensation situations
• Stand-alone dental coverage
• Stand-alone prescription drug coverage
• Vision care services
• Hearing care services

HOW TO AVOID BLUECARD® CLAIM REJECTIONS

Below are the most frequent BlueCard® claim rejection messages. We offer suggestions for what you can do to avoid having your BlueCard® claims rejected.

No Record of Membership

Validate the BlueCard® member’s ID card at each visit to ensure that you have the member’s most current information.

Claim Submitted with an Incorrect ID Number

Be sure to include the member’s complete ID number when you submit the claim. Claims with incorrect or missing prefixes and member ID numbers delay claims processing.

If the patient’s ID card does not include a prefix, call the member’s Blue Cross and/or Blue Shield Plan for claim submission instructions.

Care After Coverage Termination Date

Verify the member’s BlueCard® eligibility and coverage by:

Phone: Call BlueCard® Eligibility at 1-800-676-BLUE (2583).

Follow the prompts and the automated system will ask you for the prefix on the member’s ID card. You will be connected to the Customer Service team at the member’s Blue Plan. If you are unable to locate a prefix on the member’s ID card, review the ID card for the phone number of the member’s Blue Plan and call the Plan directly for information.

Online: Log on to NaviNet.net and select Horizon from the My Health Plans menu. Then,

• Mouse over Eligibility & Benefits and click Eligibility & Benefits Inquiry.
• Select Out Of Area – BlueExchange®/FEP® in the Inquiry Type section.
• Enter the required BlueCard® member information.
• Click Search.

Physician Contracts with Two Plans

If your office participates directly with Horizon and another Blue Plan, and the Horizon member lives or works in New Jersey, file the claim directly to Horizon for processing.

If services are rendered in New Jersey and your office does not participate with the Plan through which the member is enrolled, submit claims to Horizon.

HOW TO AVOID DUPLICATE CLAIM DENIALS

Based on a review of BlueCard® claim denials, we found that the number one reason for BlueCard® claim denials is that the claim in question is a duplicate of a previously processed claim.

Here are some of the duplicate claim trends we uncovered as part of this review:

• Claim submissions received for patients who have Medicare as their primary insurance.
• Claim resubmissions received within two weeks of the original claim.
• Claim resubmissions received where the original claim was finalized without generating a reimbursement.

Review the guidelines here to help decrease the trends identified above

Wait for MEOBs

If Medicare is your patient’s primary insurance, submit your claim to Medicare first. The Medicare Explanation of Benefits (MEOB) you receive will indicate if the claim was automatically routed to the patient’s secondary insurance carrier. If the MEOB indicates that the claim was sent to the secondary carrier, do not resubmit it. If the MEOB doesn’t indicate that the claim was sent to the secondary carrier, submit it with the MEOB to:

• Horizon BCBSNJ BlueCard® Claims
  PO Box 1301
  Neptune, NJ 07754-1301

Check Claim Status First

Before resubmitting a claim, check the status of your claim on NaviNet.net or call our Dedicated BlueCard® Service Unit at 1-888-435-4383.

Submit Corrected Claims with a 579 Form

Ensure that corrected claim submissions are accompanied by a completed copy of our Inquiry Request and Adjustment Form (579). Be sure to specify the changes made relative to the original claim submission (revenue codes, late charges added, etc.) and include all required supporting documentation (Universal Bill [UB] form, other carrier/MEOBs, etc.).

BLUECARD® CLAIM APPEALS

Our BlueCard® claim appeal process aims to resolve BlueCard® claim appeals within 30 to 45 days of their receipt.

As part of our BlueCard® claim appeal process, we developed a BlueCard® Claim Appeal Form (5373).

The process and form only support BlueCard®-related claim appeals from hospitals on behalf of their patient.

Use of this form is not intended for non-BlueCard® claim appeals or for routine BlueCard® claim inquiries.

A BlueCard® claim appeal is a formal request for reconsideration of a previously adjudicated BlueCard® claim. The claim appeal may or may not include additional information. BlueCard® claim appeals may involve, but are not limited to, inquiries about:

• Payer allowance
• Medical policy/medical necessity determinations (e.g., cosmetic or investigational services)
• Incorrect payment or coding rules applied

The following are not considered a claim appeal and should not be submitted on the BlueCard® Claim Appeal Form (5373):

• Corrected claim submissions.
• General claim inquiries or questions.
• Claim denial requiring additional information.

Completed forms, along with necessary supporting documentation, may be mailed to:

• Horizon BlueCard® Claim Appeals
  PO Box 1301
  Neptune, NJ 07754-1301

For questions about the BlueCard® claim appeal process, call our BlueCard® Unit at 1-888-435-4383.

To avoid delays, ensure that claim appeals submitted on behalf of your patient are accompanied by a completed Consent to Representation in Appeals Form.

SUBMITTING BLUECARD® CLAIM APPEALS THROUGH NAVINET

• Log on to NaviNet.net.
• Select Horizon from the My Health Plans menu.
• Mouse over Claim Management and select Claim Status Inquiry.
• Locate the claim in question and access the Claim Status Details screen.
• Click Submit Claim Appeal.¹
• Complete the requested information and attach the appropriate documentation (the system can accept up to five attachments per appeal – not to exceed a total of 10 MB – in either a PDF, JPG or TIF format).
• Click Submit.

Once an appeal is successfully submitted, a confirmation screen will display with an appeal confirmation number for your records. To help prevent duplicate claim appeal submissions, only one submission will be accepted within a 45-day period for a particular claim.

If you have questions about the BlueCard® appeal process, call our Dedicated BlueCard® Unit at 1-888-435-4383.

¹ The Submit Claim Appeal function will only display if the BlueCard® claim in question is finalized with a zero paid amount and includes a claim message. Claims that are partially paid (one line is approved for reimbursement but another line is denied) must be appealed by mail and accompanied by a completed BlueCard® Claim Appeal Form (5373) available within the Forms section of our website.

BLUECARD® HELPFUL HINTS

Send medical records when:

• Requested in writing by Horizon.
• Requested by the BlueCard® Home Plan.

Do not send medical records:

• When a retrospective review is done by the Utilization Review Department via a phone call.
• For a second level medical appeal.

OTHER BLUECARD® COVERAGE TYPES ALTNET

Though most BlueCard® members access their in-network level of benefits when they use participating providers within our Horizon PPO network, there are also a number of national account groups enrolled through out-of-area

Blue Cross and/or Blue Shield Plans whose members reside in New Jersey and who access their in-network level of benefits only when they use physicians, other health care professionals, hospitals or ancillary providers that participate in our Horizon Managed Care Network.

These BlueCard® plans that use our Horizon Managed Care Network are also known as Alternate Network BlueCard® (AltNet) plans.

Special features of these national account group plans include:

• The option to select a Primary Care Physician (PCP)
• No referrals
• Fee-for-service reimbursement for eligible services at the Horizon Managed Care Network allowance

In-Network Benefit Level

To maximize their benefits, AltNet plan members must use physicians, other health care professionals or facilities that participate in the Horizon Managed Care Network. Reimbursement for eligible services will be calculated based on our Horizon Managed Care Network rates.

Out-of-Network Benefit Level

Out-of-network benefits apply to members who use other physicians, health care professionals or facilities, including physicians or health care professionals who participate only in our Horizon PPO Network. Reimbursement for eligible services will be calculated based on our Horizon PPO Network rates.

AltNet ID Cards

The member ID cards for AltNet plans include the PPO-in-a-suitcase logo. This logo indicates that these BlueCard® members have access to in-network coverage when traveling outside New Jersey. Alt-Net ID cards will also include the words Horizon Managed Care Network adjacent to that PPO-in-a-suitcase logo.

AltNet Groups in Our Service Area

The list below will help you identify members enrolled in an AltNet plan.

Prefix Group Name

ANX Assisted Living
BVV, BVY, BWJ, BIQ, BIZ, BYX, BYE Bed, Bath & Beyond
CVP Omnicom
EYR Modelez International (Kraft)
EYZ Autozone
FIO Ford Motor Company
FJF Pepsico
FWJ Ferguson Enterprises
GJW John Wiley & Sons
GXX General Motors
GZD Penske Automotive
HTJ HSBC
HTP Crestline Hotels and Resorts, LLC
JBJ JB Hunt
JDU, JEE, JEJ Chubb
JNW Walgreens
LGV Local 53 Health Benefits Fund
LZU Novartis
MZT 3M
OZB ABC Supply Company
PUB, PYJ PSE&G Long Island
QGJ, SBU, SNA Silgan Containers
TPP NYC Transit
MTA TYN, TZF, TVV, TUL TD Bank
TQL, TUV, TQW, UAA,UGZ, UMW UAW Retiree Medical Benefits Trust (URMBT)
UGK Central Garden & Pet
VJS Sears Holdings Corporation
VWA Advance Auto Parts
WES Walmart

GEOBLUE®

GeoBlue, in partnership with Blue Cross and/or Blue Shield Plans, provides BlueCard® coverage for internationally-based employees of large group employers.

GeoBlue members are enrolled in a Blue Cross and/or Blue Shield product and have full access to the BlueCard® provider network. As with other BlueCard® members, please treat patients with GeoBlue coverage the same as you would a local Horizon member. Doing so will increase your patients’ satisfaction and improve their overall BlueCard® experience.

GeoBlue ID Cards

GeoBlue member ID cards contain all BlueCard® specifications and all BlueCard® processes that apply for coverage and claims.

The GeoBlue ID card shows the member contract number, including the three-letter alpha prefix, and has the Blue Cross and Blue Shield symbols prominently displayed on the front.

GeoBlue Eligibility and Benefits

To verify eligibility and benefits of a GeoBlue member, call GeoBlue Customer Service at 1-855-282-3517.

You may also log in to NaviNet and use the BlueExchange® option within the Eligibility and Benefits Inquiry capability.

GeoBlue Claims

Claims for GeoBlue members should be submitted electronically using NaviNet or through your vendor using Payer ID 22099. If you have to mail your claims, please send to:

• Horizon BCBSNJ BlueCard® Claims
  PO Box 1301
  Neptune, NJ 07754-1301

Be sure to include the member’s complete ID number when you submit claims. Incorrect or missing prefixes and member ID numbers delay claims processing.

GeoBlue Claim Inquiries

For GeoBlue claim inquiries, call Horizon’s BlueCard® Unit at 1-888-435-4383 or visit NaviNet.net.

OUT-OF-STATE MEDICAID MEMBERS

The BlueCard® Program can also be used to submit most claims for certain out-of-state Medicaid members you may treat. Horizon NJ Health is your one point of contact for Medicaid claims or Medicaid claims-related questions.

Medicaid programs in the following states (and commonwealths)¹ are administered by Blue Cross Blue Shield Plans:

California
Delaware
Hawaii
Illinois
Indiana
Kentucky
Michigan
Minnesota
New Jersey
New Mexico
New York
Pennsylvania
Puerto Rico
South Carolina
Tennessee
Texas
Virginia
Wisconsin

If you see patients enrolled in one of these Medicaid programs, we remind you that claims should be handled as you would other BlueCard® Program claims.

This information is accurate as of the posting date. Updated information, as it becomes available, will be included on Horizon NJ Health’s Resources page.

Identifying Medicaid Members to Determine Eligibility and Benefits

BCBS Plan ID cards may not always indicate that a member has a Medicaid product.

BCBS Plan ID cards for Medicaid members do not include the suitcase logo that you may have seen on most BCBS ID cards, but they do include a disclaimer on the back of the ID card providing information on benefit limitations. For members with such ID cards, you should obtain eligibility and benefit information and prior authorization for services using the same tools as you would for other BCBS members.

• Submit an eligibility inquiry by calling the BlueCard Eligibility Line at 1-800-676-BLUE (2583).
• Submit an eligibility inquiry using BlueExchange.
• Obtain pre-service review using the Electronic Provider Access (EPA) tool.

Provider Enrollment Requirements

Because Medicaid programs are state-run programs, requirements vary for each state, and thus each BCBS Plan.

Some states require that out-of-state providers enroll in their state’s Medicaid program in order to be reimbursed. If you are required to enroll in another state’s Medicaid program, you should receive notification upon submitting an eligibility or benefit inquiry.

You should enroll in that state’s Medicaid program before submitting the claim. If you submit a claim without enrolling, your Medicaid claims will be denied and you will receive information from your local BCBS Plan regarding the Medicaid provider enrollment requirements.

Visit Horizon NJ Health’s Resources page to review enrollment requirements for BCBS Medicaid states.

Medicaid Billing Data Requirements

When billing for a Medicaid member, please remember to check the Medicaid website of the state where the member resides for information on Medicaid billing requirements.

Medicaid claims must include the following data elements:

• Rendering Provider Identifier (NPI)
• Billing Provider Identifier (NPI)
• National Drug Code (as appropriate)

Medicaid Reimbursement and Billing

When you see a Medicaid member from another state and submit the claim, you must accept the Medicaid fee schedule that applies in the member’s home state. Remember that billing out-of-state Medicaid members for the amount between the Medicaid-allowed amount and charges for Medicaid-covered services is specifically prohibited by Federal regulations (42 CFR 447.15).

If you provide services that are not covered by Medicaid to a Medicaid member, you will not be reimbursed. You may only bill a Medicaid member for services not covered by Medicaid if you have obtained written approval from the member in advance of the services being rendered.