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Billing Guidelines & Resources

Here are some billing guidelines & resources. See our Claim Submission page when you’re ready to submit claims to us. 

 Registered Provider Central users can access additional resources on the site, such as fee schedules and payment policies.

Dental services

Use the following information to understand billing for dental services rendered by national dental network providers:

 Dental Blue Book (administrative policies)
 CDT Dental Procedure Guidelines and Submission Requirements
 Pediatric Essential Health Benefits Dental Procedure Guidelines & Submission Requirements

Non-participating provider services

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About the No Surprises Act

The No Surprises Act, enacted as part of the Consolidated Appropriations Act (“CAA”) in late 2020, provides new federal consumer protections against balance billing for certain medical bills under certain circumstances. Claims subject to balance billing protections may occur:

  • In emergency situations when a patient can’t control who is involved in their care
  • In non-emergency situations when they schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider
  • When out-of-network air ambulance services are provided for services that would have been covered if the air ambulance provider was in-network. 

Ground ambulance claims are not included under the No Surprises Act. 

Member rights and protections

We want to let you know how we’re educating our members about their rights and protections under the law. We are posting disclosures explaining the rights and protections our members have under the law to our public website in late December: bluecrossma.org/disclaimer/member-rights. Our Explanation of Benefits (EOB) when we pay bills covered by the law will direct members to the following explanation of the law:

Emergency services
If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.

Certain services at an in-network hospital or ambulatory surgical center
When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed. If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.

You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.

When balance billing isn’t allowed, you also have the following protections:

  • You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.
  • Your health plan generally must:
    • Cover emergency services without requiring you to get approval for services in advance (prior authorization).
    • Cover emergency services by out-of-network providers.
    • Base what you owe the provider or facility (cost-sharing) on what you would pay an in-network provider or facility and show that amount in your explanation of benefits.
    • Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.
Non-participating provider rights and responsibilities

Under the No Surprises Act, non-participating providers are prohibited from balance billing under the circumstances described above.

The statute requires providers, including hospitals, to make notice about balance billing requirements and prohibitions publicly available and provide them to consumers. The regulations supporting the No Surprises Act detail information that must be included in such notice.

The federal law also includes provisions allowing providers to request negotiation of the payor’s payment for bills subject to the No Surprises Act, and if negotiation fails, to enter into the Independent Dispute Resolution (IDR) process, also known as arbitration, to determine the allowed payment amount. 

  • If the provider or facility wishes to initiate a 30-day open negotiation period for purposes of determining the amount of total payment, please contact:
    Mail: Blue Cross Blue Shield of MA
    Provider Appeals
    PO Box 986065
    Boston, MA 02298

    Please include "Surprise Bill Negotiation Request" in the header of your letter.

    Phone: 1-800-882-2060 (physicians)
    1-800-451-8123 (hospitals)
    1-800-451-8124 (ancillary providers)
    Email: PSRequest@bcbsma.com

    Please include "Surprise Bill Negotiation Request" in the subject of your email.

    The request should include both the Open Negotiation Notice and the Request for Claim Review forms.

  • If that 30 day open negotiation period does not result in a determination, generally the provider or facility may initiate the IDR process within 4 days after the end of the open negotiation period. To initiate the IDR process, submit requests in writing to: Please be sure to include all information required by the No Surprises Act. For the Independent Dispute Resolution (IDR) process, the provider must furnish the Notice of IDR Initiation to the Department of Health and Human Services on the same day the notice is furnished to MultiPlan.

Other services

 Patient Protection and Affordable Care Act Preventive Care Services Billing Guideline
Use this billing guideline for information on certain preventive care services that are available without a cost to members. As always, please check member benefits and eligibility.

 Durable medical equipment

Refer to our General Coding and Billing payment policy () for information regarding:

  • Assistants
  • Locum tenens (when a physician works in place of another physician)
  • Assist at surgery
  • Payment for clinician services in a hospital teaching setting only
  • Modifiers 25, 59, XE, XS, XP, and XU