 Blue cross and blue shield of North carolina (BCBSNC)
QUICK REFERENCE Guide #1 GUIDE #1
NOTE: BCBSNC Corporate Medical Policy for Chiropractic takes precedence over any information you receive when verifying benefits from BCNSNC telephone representatives for BCBSNC members, NC State Employees, Federal Employees, and BCBSNC self funded groups. Always contact your CNC Provider Rep to determine if a particular service is consistent with BCBSNC corporate medical policy. (You may view BCBSNC Corporate Medical Policy under the provider section of their website: www.bcbsnc.com)
All claims for COVERED SERVICES provided to a beneficiary of a CNC contracted payor MUST be submitted to CNC. Participating providers who fail to submit all such claims to CNC may lose thier status as a Network Provider. (This includes any self-funded groups who utilize a CNC contracted payor as a third party administrator.)
Waiving Co-payments, Deductibles and Coinsurance
It is unlawful to waive co-payments, deductibles, coinsurances, or other patient responsibility
payments and is specifically prohibited by our contracted managed care partners.
This includes accepting a "lower" co-payment amount than the amount indicated on the member's subscriber ID card, waiving co-payments including for services deemed “professional courtesy” and TWIP (take what insurance pays).
Absent true financial hardship (with complete, current, supporting, documented evidence of such hardship maintained in the patient’s health record), the full amount of the co-pay as well as ALL co-payments, deductibles and coinsurance due and owed must be collected by all network providers.
For CNC Contracts:
Failure to consistently comply for individuals covered by a CNC contracted payor is in violation of the policies of our contracted payors and may result in the termination of your status as a CNC participating provider.
For Medicare:
Failure to comply for individuals covered by Medicare is a violation of the Federal False Claims Act,
Federal Anti-Kickback Statute, and the Federal and State Insurance Fraud Laws. Failure to comply may
result in civil money penalties in accordance with the new provision section 1128 A(a)(5) of the Health
Insurance Portability and Accountability Act of 1996 [section 231(h) (HIPAA).
REMEMBER THAT EFFECTIVE January 1, 2006, BCBS member ID numbers for ALL BCBS in-state plans:
1. must contain a 4 digit alpha prefix (ex: YPPW, not YPP)
2. no longer uses the member's social security number as part of the member
ID number.
For BCBS out of state plans that have no group number on the member ID card, always use the alpha prefix of the member ID number as the group number.
For BCBS claims, the vast majority of ID cards, list an employer. If there is an employer listed on the card, it must be included in box 11b on the HCFA. However, if the member is self-employed, then list the name of his/her company, such as John Smith, Inc. or you may simply list the name of the member in box 11b.
PLEASE REMEMBER: BCBSNC (IN-STATE ONLY) CARDS THAT CONTAIN THE SUITECASE LOGO
SHOULD BE SENT DIRECTLY TO CNC - REGARDLESS OF WHETHER "PPO" APPEARS IN THE SUITCASE.
BCBS OUT-OF-STATE CARDS THAT HAVE A SUITCASE WITH "PPO" IN THE SUITCASE SHOULD BE SENT TO CNC
BCBS OUT-OF-STATE CARDS THAT HAVE THE SUITCASE LOGO, BUT DO NOT CONTAIN "PPO" WITHIN THE SUITCASE, SHOULD BE SENT DIRECTLY TO BCBS IN DURHAM, NC
WHEN IN DOUBT, FAX US A COPY OF THE CARD. WE WILL GLADLY ASSIST YOU!
BCBSNC Quick Reference Guide #1 for:
BlueCross and BlueShield of North Carolina (BCBSNC)
Blue OptionsSM, a preferred provider organization (PPO) plan
Classic Blueâ, an indemnity/comprehensive major medical (CMM) plan
Do not send CNC claims directly to BCBSNC! Send all "CNC" claims to CNC!
Ignore the claims billing address on the member ID card or given to you on the telephone when verifying benefits. You are under contract through CNC and our instructions for filing claims override information given to you by BCBSNC!
 Eligibility/Benefits
When calling BCBSNC to verify benefits, ALWAYS USE THE CNC PROVIDER NUMBER, 0194L
rather than your provider's own BCBS provider number.
- You can now use Blue esm to verify eligibility for BCBS members! (If you are not contracted with Blue eSM , please click here for information and instructions on how to sign up!
- If you do not have Blue eSM yet, call the Provider Blue Line to verify benefits:
1-800-214-4844. Provider Blue LineSM Representatives are available:
8:00 AM to 5:00 PM, Monday through Friday. Remember to use the CNC provider number 0194L when calling BCBSNC.
- Chiropractic benefits are limited to a maximum 30 visits per benefit period for combined chiropractic, physical therapy, occupational and speech therapy visits. Chiropractic benefits vary by employer group. Ask for specific information on Chiropractic benefits for each member.
Referrals
Blue Options or Classic Blueâ are direct access plans.
No referral from a PCP is needed.
- When necessary to refer to another health provider, referrals within the network are strongly recommended.
Co-payment/Co-insurance Collection
- No money is collected at the time of service unless there is a co-payment amount stated on the ID card. We recommend that you always ask whether the member’s plan has a co-payment or deductible when verifying benefits.
The effective date of the NC legislation regarding the change in co-payments from specialist to PCP was March 1, 2006. Co-payments will change between March 1, 2006 and March 1, 2007, AS EACH MEMBER’S PLAN RENEWS. By March 1, 2007, all plans will have renewed and the correct co-payment will be the “primary care co-payment.” Please remember that plans renew throughout the year, not just in January!
ALWAYS VERIFY CO-PAYMENT AMOUNT
FOR EACH MEMBER THROUGHOUT THE YEAR!
Exception:
Effective January 1, 2006, BCBSNC Blue Advantageâ members’ co-payments changed from Specialist to Primary Care Provider. (PCP)
- Once you receive your Explanation of Payment, provider may bill for any deductible or co-insurance up to BCBSNC’s allowed amount.
- Provider may not bill the member for the discount amount on covered services.
- Non-covered services may be billed at the provider’s normal charges, if the member was advised in writing, in advance, that the services would be non-covered.
CLAIMS SUBMISSION
Submit all CNC claims to:
CNC
PO Box 2368
Cornelius, NC 28031
Please IGNORE THE ADDRESS ON THE MEMBER'S ID CARD or ANY ADDRESS GIVEN TO YOU BY PHONE WHEN VERIFYING BENEFITS and SEND ALL CLAIMS TO CNC!
Please refer to the CNC Billing Instructions for complete information on claims submission.
REMEMBER THAT EFFECTIVE January 1, 2006, BCBS member ID numbers for ALL BCBS in-state plans:
1. must contain a 4 digit alpha prefix (ex: YPPW, not YPP)
2. no longer uses the member's social security number as part of the member
ID number.
- The claim must be identified as a BCBS claim in the address section at the top of the HCFA form (CNC/BCBS is an acceptable format). Be sure that you put the CNC address here.)
Example:
CNC/BCBS
PO Box 2368
Cornelius, NC 28031
- Claims must include your individual BCBSNC provider ID number in box 24K of the HCFA form, and your BCBSNC group ID number in box 33, if applicable.
- Claims must be identified in box 11C as BCBS
- If filing BCBS as secondary, always attach a copy of the primary EOB from the payor, and submit this, together with a new HCFA 1500 direct to CNC.
- BCBSNC reserves the right to deny payment if a claim is submitted after 180 days. As a participating provider, you may not bill the member for claims submitted after 180 days.
Claims Inquiries
You can now check the status of your claims online with the new Blue eSM product. If you have not signed up for Blue eSM, please click here for information on how to sign up!
- (If you have signed up for Blue eSM but have not received your user ID yet, please contact CNC and we will follow up and assist you with obtaining this great service. In the interim, for tracing overdue claims (after 30 days from your billing date), complete your CNC Fax Inquiry Form and fax this form, together with the requested information to CNC. We will gladly trace the claim for you!
- When using the automated system, you will need to have the patient’s ID, date of birth and date of service available.
- Resubmit corrected/lost/missing claims through CNC.
- For questions relating to payment of a claim, please do not contact BCBSNC. PLEASE USE YOUR Blue eSM online service. or use your
CNC Fax Inquiry Form and fax to (704) 895-8664.
- Refer to your CNC/BCBSNC Blue OptionsSM or Classic Blueâ fee schedule to confirm allowable amounts and CPT codes.
BCBSNC
HSA/HRA
(INSTRUCTION GUIDE FOR CNC PROVIDERS)
BCBSNC introduced Health Savings Account (HSA’s) and the Health Reimbursement Arrangement (HRA’s) in January 1, 2005 as part of the Blue Options PPO product line.
To easily identify members with HRA’s or HSA’s, member ID cards will clearly state:
BlueOptionsHSA
Or
BlueOptionsHRA
Higher in-network benefits are available to BlueOptionHRA and BlueOptionHSA members who seek care within the PPO provider network.
Each time one of these cards is presented, the provider should first carefully review the member’s card. If the card indicates a co-payment amount, the provider should collect ONLY the co-payment from the member, as usual, and submit the claim to CNC
If the card indicates a deductible and co-insurance amount, the provider must verify both the deductible and coinsurance amounts. To assure that you are receiving the most current information, you should obtain this information from Blue e. (If you have yet registered for Blue e, please contact CNC directly and we will assist you with registering for this great service!) Until you have registered for Blue e, contact BCBSNC Customer Service to verify deductibles and co-insurance. Once these amounts have been verified, the provider may choose one of two options:
The provider may submit the claim to CNC, wait for the EOP, and then bill the member for the appropriate amount due the provider
Or
The provider may collect up to the lesser of the member’s estimated out-of-pocket costs or $50.00, for services received in the provider’s office. The estimated amount must be based on the CNC allowables, not the provider’s billed charges. Providers must inform the member that the amount being collected is an estimate only. If the member is unable to pay at the time of service, the provider should not refuse to provide necessary treatment to the member. If they choose, (and if funds are available) the member can use funds from their HSA or HRA to pay for these services. The provider should submit the claim to CNC as usual.
The final determination of what the member owes will be based on the claim that is submitted to BCBSNC and will be reflected on the EOP. Any applicable refunds due to the member must be returned within 45 days.
For additional information regarding BCBSNC HSA/HRA’s, please refer to the 2006-2007 BCBSNC Blue Book, 3-39.
Provider Relations
Questions relating to your participation in BCBSNC products should be directed to CNC
at 704-895-8117, EXT. 2.
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