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.
