The BlueCard® program is a national program that enables members of another Blue Cross Blue Shield plan to get health care service benefits while traveling or living in another Blue plan’s service area.
For claim questions, contact your local, in-state Blue plan.
The program links participating health care providers and the independent Blue Cross Blue Shield plans across the country through a single electronic network for claims processing and reimbursement.
Blue High Performance Network
Blue Plans may also offer plans with a national limited network of providers called the Blue High Performance NetworkSM (Blue HPNSM). In Massachusetts, this national network will be paired with our Exclusive Provider Organization (EPO) plan, Advantage Blue Performance. Coverage in plans with the Blue HPN are limited to emergency services at a hospital only when performed by non-HPN providers.
Plan: One of the 34 independently operated “Blue Plans” in the Blue Cross and Blue Shield System.
Home plan (member’s plan): The Blue Cross plan the member has a contract with. The member’s benefits are determined by their Home plan.
Local plan: The area where the member got their care. Blue Cross Blue Shield of Massachusetts is usually considered the Local (or Host) plan. Contact us for all claims inquiries and follow-up. The Blue Cross electronic network enables accurate and timely payments, eliminating the need to track receivables from multiple carriers.
Here is a description of the Local plan for clinical laboratories and durable medical equipment providers:
| The Local plan for a | Is defined as the plan in the service area where |
|---|---|
| Clinical laboratory | The specimen was drawn, which is determined by the location of the referring provider. |
| DME provider | The equipment was shipped or purchased at a retail store. |
BlueCard members have a suitcase logo on their ID card.
Blue Cross Blue Shield member ID numbers begin with a three-character prefix and can be up to 17 characters long. With any claim or electronic transaction, be sure to enter the ID number exactly as it appears on the member’s card.
You can recognize patients with Blue HPN (a limited network of providers) by the Blue High Performance name and the “BlueHPN in a suitcase” logo on the member ID card (shown below).
You can follow the same pre-service review and claims filing procedures you use today for BlueCard PPO patients.
Note that the level of detail returned in your results will vary from Plan to Plan.
You can determine eligibility for out-of-area Blue Cross Blue Shield members by:
- Using ConnectCenter
- Submitting a HIPAA-compliant 270 through Direct Connection or through a clearinghouse
- Calling BlueCard® Eligibility at 1-800-676-BLUE (2583).
Verifying that a referral is on file and that the number of requested visits matches the services required helps facilitate the claims process and avoids unnecessary appeals or inquiries.
Enter and verify referrals electronically, the same way you do for Massachusetts members.
You can enter and check referrals for all members in managed care plans by:
- Using ConnectCenter
- Submitting a HIPAA-compliant 278 through Direct Connection or through a clearinghouse
You can submit pre-certification and pre-authorization requests for out-of-area Blue Cross Blue Shield members by:
- Submitting a HIPAA-compliant 278 through Direct Connection or through a clearinghouse
- Using the Pre-service Review for BlueCard members tool for our out-of-area members
- Calling BlueCard® Eligibility at 1-800-676-BLUE (2583). You can choose from four options depending on the type of service you need an authorization for:
- Medical/surgical
- Behavioral health
- Diagnostic imaging/radiology
- Durable medical equipment (DME)
Submit claims the same way you do for Massachusetts members.
Yes. Participating providers must get pre-service, preauthorization review for inpatient facility services for out-of-area BlueCard® members, when it is required by the member’s subscriber certificate or the account. If you don’t get preauthorization review, the facility will be held financially responsible.
If the member’s primary insurer is Blue Cross Blue Shield, you must contact the Local plan. The Local plan is responsible for processing the claim.
To check the status of a claim, please use ConnectCenter. If the claim has been processed, you can also find its status in Payspan.
Based on our contractual arrangement with you, you may not balance bill the BlueCard member for the difference between our allowance and your charge.
BlueCard Program claims we process will appear on your Provider Detail Advisory (PDA) and Provider Payment Advisory (PPA). The PDA will indicate any co-insurance or deductibles you can collect directly from the member.
After the member’s plan applies benefit and eligibility information, we adjudicate the claim according to your contracted Agreement with us. We will reimburse you as part of our normal payment cycles provided that the member is eligible, the services are covered, and you have not already been paid for your services.
POS members
- Reimbursements for BlueCard managed care point-of-service (POS Blue Choice) claims follow the same reimbursement guidelines as standard POS (Blue Choice) claims.
PPO and EPO members
- If you are a Blue Care Elect provider, we will reimburse you for BlueCard Preferred Provider Organization (PPO)/Exclusive Provider Organization (EPO) members based upon the PPO fee schedule as provided in your Agreement with us.
- If you are not a Blue Care Elect provider but participate with Blue Cross Blue Shield of Massachusetts, we will process the claim based on the member’s coverage.
- EPO members have limited or no benefits for services rendered by a provider outside of the PPO network.
Indemnity/Traditional
- Providers will be reimbursed for covered services in accordance with our indemnity/traditional fee schedule.
When an out-of-state or international Blue Cross Blue Shield plan member visits you:
Step  |
Ask for the member’s most current domestic or international ID card (because coverage and ID numbers may change). All domestic cards will have the Blue Cross logo, a three-character prefix and a suitcase logo. |
Step  |
Verify eligibility and coverage with the member’s plan. Call
1-800-676-BLUE (2583) for information about:
You can also check eligibility electronically using Online Services, submitting a HIPAA-compliant 270, or using other electronic tools. |
Step  |
The doctor or admitting hospital requests authorization from the Home plan for inpatient admissions. We will reject claims if you don’t request preauthorization. |
Step  |
Collect any member cost share for services. This should be the same type of out-of-pocket expenses (deductible, copayment, co-insurance, non-covered services) as you currently collect for in-state or domestic Blue Cross Blue Shield members. |
Step  |
Submit the claim to the Local plan. Make sure the member’s ID number and prefix are correct. This information is used to send BlueCard Program claims electronically to the member’s plan for processing. |
Step  |
The member’s plan reviews the claim and transmits its response to us, either approving or denying payment. |
Step  |
We finalize the claim and send you payment or notification via our Provider Payment Advisory (PPA) and Provider Detail Advisory (PDA). |
Step  |
The member’s plan sends a detailed explanation of benefits to the member. |
The New England Health Plans (NEHP) are managed care products that offer accounts a regional managed care benefit plan that covers all employees regardless of where they live or work in New England.
The NEHP managed care products are the result of collaboration among the six New England Blue Cross Blue Shield (BCBS) Plans created to simplify claim processing for health care Providers and enrollment for Members. Participating BCBS Plans include:
Home/Host Plans:
- Anthem Blue Cross Blue Shield of Connecticut
- Anthem Blue Cross Blue Shield of Maine
- Anthem Blue Cross Blue Shield of New Hampshire
- Blue Cross Blue Shield of Massachusetts
- Blue Cross Blue Shield of Rhode Island
Host Plan Only:
- Blue Cross Blue Shield of Vermont
The Home Plan is the BCBS Plan with whom the Member has a contract. The Member’s benefits are determined by the Home BCBS plan.
The Host Plan is the BCBS Plan where the Member is receiving services if outside of their Home Plan.
BCBSMA offers health maintenance organization (HMO) and point-of-service (POS) plan designs through these five products:
HMO
- HMO Blue New England
- Network Blue New England®
- Access Blue New England
POS
- Blue Choice New England®
- Blue Choice II New England®
HMO Blue New England plans require a primary care provider (PCP) for the coordination of the member's care and for referrals to an in-network specialist.
Blue Choice New England plans require a PCP for the coordination of the members care, but provides the member the flexibility to self-refer to any BCBS-participating provider.
Access Blue New England plans require a PCP for the coordination of the members care, but provides the member the flexibility to self-refer to specialists within the network.
You can identify NEHP Members by their BCBS Plan ID card. Be sure to ask all visiting members for their ID card. The main identifier for NEHP Plans is the name of the health plan/product in the upper right-hand corner of the ID card, and the three-character prefix preceding the ID. You’ll also see the suitcase logo on the card. Identifying members from other states is easy. Below we’ve listed the ID card prefixes for each state offering plans. Members from other states may be entitled to additional mandated benefits.
| State | Prefix |
|---|---|
| Connecticut | CTN, CTP, EHF, APQ, APR, APG |
| Maine | MEN, MEP, EHG, BFZ, BDD, BHI, XJV, MEY, TXH |
| New Hampshire | NHN, NHP, EHH, BKA, NMY, BYV, YGI, BPP, YGE, ZZG, YGL, ZXW |
| Rhode Island | RIN, RIS, RIA |
Referrals
Primary care providers: For NEHP members, submit referrals to the local plan (that is, the plan in the state where you’re located).
Visit our Referrals page for more information about which services require a referral.
To learn about standard authorization requirements, download our Authorization Quick Tip.
Blue Cross Blue Shield Global offers insurance coverage to foreign Blue Cross members who are living or traveling in the United States, and it also provides coverage for domestic members who are traveling or living abroad.
When your patients travel overseas
Your Blue Cross Blue Shield members can receive inpatient and outpatient services through the Blue Cross Blue Shield Global Core Program when they travel outside of the United States or live overseas. Blue Cross Blue Shield Global Core-participating hospitals are located in major travel destinations and business centers in more than 200 countries. (Medicare Advantage members are ineligible for the Blue Cross Blue Shield Global Core Program.)
When a member requires inpatient care abroad, they will need to call the Blue Cross Blue Shield Global Core Service Center at 1-800-810-BLUE (2583), show their Blue Cross ID card to the provider, and call their Blue Plan for precertification. In most cases, members will not need to pay upfront for inpatient care coordinated by Blue Cross Blue Shield Global Core except for out-of-pocket expenses (non-covered services, deductible, copayment and co-insurance) they would normally pay. Members will be required to pay for outpatient services and professional services up front and submit a Blue Cross Blue Shield Global Core International claim form with an itemized bill for reimbursement to the Blue Cross Blue Shield Global Core Service Center. Blue Cross Blue Shield Global Core also provides medical assistance services and interpreters.
For a list of Blue Cross Blue Shield Global Core-participating hospitals, or for help in locating a professional provider, call the Service Center at 1-800-810-BLUE (2583) or visit bcbsglobalcore.com.
Out-of-country members receiving services in the United States
BUPA Global/Geo Blue members traveling from out of country to the United States can receive medical services through Blue Cross Blue Shield Global. You may collect the same type of out-of-pocket expenses (deductible, copayment, co-insurance, non-covered services) as you currently collect for in-state or domestic Blue Cross Blue Shield members. Please verify eligibility and coverage for these members by calling 1-800-676-BLUE (2583). Claims for these members should be submitted to your local Plan using the same claim submission process you use currently for in-state or domestic BlueCard members.
Medicare PPO Blue offers a Visitor/Traveler Program that includes in-network benefits and cost-sharing when a member receives treatment for covered services from participating Blue Medicare Advantage PPO network providers outside of their Home Plan.
There are network providers in the following states: Alabama, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia, Hawaii, Iowa, Idaho, Illinois, Indiana, Kansas, Kentucky, Louisiana, Massachusetts, Maine, Maryland, Michigan, Minnesota, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Puerto Rico, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Washington, Washington DC, Wisconsin, and West Virginia.
Under Medicare Advantage rules, if the member is absent from the service area for more than 6 months, the member must be disenrolled. However, in areas where we offer the Visitor/Travel Program, members may remain in the Plan while out of our service area for up to 12 months. In some cases, network providers are available in select areas of the state.
To locate a participating network provider a Member can:
- Call the Member Service phone line during regular business hours, or
- Call 1-800-810-BLUE to find a Blue Medicare Advantage PPO provider, or
- Visit the Blue National Doctor & Hospital Finder to find a Blue Medicare Advantage PPO provider.
