The BlueCard Program

The BlueCard^® Program links participating physicians, facilities and other health care professionals 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 for you to deal with multiple Blue Plans. Horizon BCBSNJ is your one point of contact1 for claims or claims related questions.

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 BCBSNJ member. Doing so will increase your patients’ satisfaction and improve their overall BlueCard experience. Billing charges in excess of the allowance is not permitted. 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 for processing.

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

¹The 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 for processing.

IDENTIFYING BLUECARD MEMBERS

Identifying BlueCard members is critical to timely and accurate claim processing and it’s easy once you know what to look for. 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 isthe first visual indicator that a member may be eligible for BlueCard benefits.

Prefix

The prefix on the member’s ID card is the key element used to identify the Blue Plan to which the member belongs and to route claims correctly.

It is critical to confirm membership, eligibility and coverage. Ask to see the member’s ID card at each visit.

If there is no prefix on a member’s ID card, that member is not eligible for benefits through the BlueCard program. In this instance, 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 shown here 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 and 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 BCBSNJ name.

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.

Calling for Information

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, call the phone number on the ID card.

Submit Information Electronically

You may also submit a HIPAA 270 transaction to Horizon BCBSNJ 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. To do so, refer to your patient’s ID card for phone number information or call 1-800-664-BLUE (2583).

Inpatient Prior Authorization/Precertification

Network facilities are required to 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 BCBSNJ claims or send paper claims 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 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 BCBSNJ and will process according to the DME provider’s contractual relationship with Horizon BCBSNJ.

However, if the equipment is purchased by or delivered to a Horizon BCBSNJ 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

Upon receipt, 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 CLAIMS AND INQUIRIES

All behavioral health (including mental 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 is84367.

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

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 alpha 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 BCBSNJ’s Dedicated 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.

Note: This claims submission information pertains only to your patients enrolled through an out-of-state Blue Cross and/or Blue Shield Plan. There is no change to how inquiries and claims should be handled for your patients enrolled through Horizon BCBSNJ.

BLUECARD CLAIM SUBMISSIONS HELPFUL HINTS

Regardless of the method you use to submit claims, be sure to include the prefix and the complete ID number. 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.

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

Horizon BCBSNJ strives to process your BlueCard claims quickly and accurately, but claim rejections do occur.

Below are the most frequent BlueCard claim rejection messages and 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 or online.

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 BCBSNJ 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 and click Search.

Facility Contracts with Two Plans

If your facility participates directly with Horizon BCBSNJ and with the Plan through which the member is enrolled, submit claims directly to that other Plan for processing.

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

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, please 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, please check the status of your claim online at NaviNet.net or by calling 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 BCBSNJ

BlueCard Claim Appeals

PO Box 1301

Neptune, NJ 07754-1301

If you have questions about the BlueCard claim appeal process, call our Dedicated 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 (also available on our website).

BLUECARD MEDICAL RECORD REQUESTS

Part of the claims process often includes requests from other Blue Cross and/or Blue Shield Plans for additional information and/or medical records to assist in the review and finalization of claims. If additional information is needed, Horizon BCBSNJ will receive a communication from the member’s BCBS Home Plan. This communication/request will specify what information is needed. Within two days Horizon BCBSNJ will process this request by sending a letter to the facility/provider. A unique medical record ID number is assigned to each letter generated. When the letter is returned along with the medical records, this unique number will allow the medical records to systemically route to the member’s home plan. If the medical records are returned and this unique letter is not included as the first page, your submission will be handled manually. These records can get misrouted as a piece of correspondence rather than a medical record, and therefore, delays the submission to the member’s plan.

BlueCard Helpful Hints

Send medical records when:

• Requested in writing by Horizon BCBSNJ.
• Requested by the BlueCard Home Plan.
• Do not send medical records:
• When a retrospective review is done by the Utilization Review Department by phone.
• 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. AltNet 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, Bed, Bath & Beyond
• BIZ, BYX, BYE
• CVP Omnicom
• EYR Mondelez 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 MedicalBenefits 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 BCBSNJ member to 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 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, 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

Horizon BCBSNJ is your one point of contact for BlueCard program (including GeoBlue) claims or claims-related questions. For GeoBlue claim inquiries, please call Horizon BCBSNJ’s Dedicated 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 locations are administered by Blue Cross and 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 on

HorizonNJHealth.com to review enrollment requirements for BCBS Medicaid states.

Medicaid Billing Data Requirements

When billing for a Medicaid member, 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. Please 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.