 Blue cross and blue shield of north carolina (BCBSNC)
QUICK REFERENCE GUIDE #3
NOTE: BCBSNC Corporate Medical Policy for Chiropractic takes precedence over any information you receive 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.)
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 11 on the HCFA. However, if there is no employer listed on the card, you may leave box 11 blank.
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 #3 for:
Blue Careâ, an open access health maintenance organization (HMO) plan
Do not send claims directly to BCBSNC! Send all "CNC" claims to CNC! Ignore the claims billing address on the member ID card or any address 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 Representatives regarding where to send claims!
Blue Careâ is an open access HMO product that does not require the member to obtain a referral from their primary medical doctor (PMD) in order for benefits to be considered.
For Blue Careâ, chiropractic benefits are limited to those groups who have purchased the chiropractic endorsement. If a group has not purchased the chiropractic endorsement, there are no benefits available. When a group has purchased the chiropractic endorsement, benefits are limited to a maximum of 20 visits per benefit period. Benefits are paid only to participating providers. There are no out-of-network benefits available.
 Eligibility/Benefits
When calling BCBS to verify benefits, REMEMBER TO USE THE CNC PROVIDER NUMBER 0194L,
rather than YOUR provider's individual BCBS provider number.
You can NOWA 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 LineSM: 1-800-214-4844 to verify benefits. 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 verifying benefits.
- Chiropractic benefits vary by employer group. Ask for specific information on Chiropractic benefits for each member.
- Chiropractic benefits are limited to those members whose employer has purchased the chiropractic endorsement. If an employer has not purchased the chiropractic endorsement, there are no benefits available.
- When a member’s employer has purchased the chiropractic endorsement, benefits are limited to a maximum of 20 visits per benefit period.
Referrals
- No referral is required from a member’s PMD (primary medical doctor) for either Blue Careâ .
Co-payments
Collect the co-payment at the time of service for each visit!
FOR NORTH CAROLINA PROVIDERS ONLY:
Due to the new legislation, co-payments for chiropractic visits will change from
the SPECIALIST CO-PAYMENT to the PRIMARY CARE (PCP) PROVIDER
CO-PAYMENT. The co-payments will change from the specialist to the PCP
co-payment, 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)
Claims Submission
Submit all claims to:
CNC
PO Box 2368
Cornelius, NC 28031
Please ignore the address on the member ID card or any address given to you when verifying benefits and send all claims to CNC.
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.
Please refer to the CNC Billing Instructions for complete information on claims submission. The following information is additional information regarding claims submission specific to this contract.
- 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 either “BCBS BlueCare or “BCBS BlueChoice” (CNC, Blue Cross Blue Shield of NC or Major Medical are not acceptable in this box)
- If filing BCBS as secondary, always attach copy of the primary EOB from the payor, and submit this, together with a new HCFA 1500 direct to CNC.
- 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.
- 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
- (If you have signed up for Blue eSM but have not received your user ID yet, please contact CNC and we will assist you. 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 BlueCareâ fee schedule to confirm allowable amounts and CPT codes.
Provider Relations
Questions relating to your participation in these BCBSNC products should be directed to CNC
at 704-895-8117, EXT 2.
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