out of state BCBS claims - who submit claims and where

BCBS Claims

When I receive services outside the State of Florida, who submits the claim to BCBSF? 

If the physician or provider is participating in the Blue Cross and Blue Shield network in that state, they will submit the claim for you. If not, then you will be responsible for submitting the claim to BCBSF. 

What makes up Member Responsibility 

Member Responsibility is the out-of-pocket portion of a claim that a member is expected to pay. For example, deductibles, copayments, and non-covered services are considered Member Responsibility. 

How do I obtain information on my right to appeal? 

View information about your Appeals Rights

     BlueCare (HMO) Members

     BlueChoice, BlueOptions, BlueSelect, GoBlue and Florida Healthy Kids Members.

Do I have to submit claims? 

Not if you choose a provider from within your plan provider network. Your provider should process all claim submission paperwork on your behalf. If you choose a provider outside the network, you may have to file claims for reimbursement.

BCBS alpha prefixes list and claim submission address - Updated list.

Its often confused that BCBS have lot of prefixes and where to contact. However we have some guide to follow, using prefixes we could find the state of the BCBS and contact phone number to proceed further. Use find (Ctrl + F) and enter the prefix to find the BCBS state.

BCBS Alpha Prefixes

Most BCBS-branded ID cards display a three-character alpha prefix in the first three positions of the member’s ID number. However, there are some exceptions. ID cards for the following products and programs do not have an alpha prefix:

** Stand-alone vision and pharmacy when delivered through an intermediary model*

** Stand-alone dental products*

** The BCBS Federal Employee Program (FEP) – The letter “R” appears in front of the ID number.*

*Follow instructions on these ID cards to verify eligibility, submit claims and obtain health plan contact information.

The alpha prefix is critical for inquiries regarding the member, including eligibility and benefits, and is necessary  for proper claim filing.

** When filing a claim, always enter the ID number, including the alpha prefix, exactly as it appears on the member’s card.

** Always include the member’s ID number, including the alpha prefix, on any documents pertaining to services to ensure accurate handling by the BCBS Plan.

A member’s ID number includes the alpha prefix in the first three positions and all subsequent characters ‒ between 6 and 14 numbers or letters ‒ up to 17 characters total. The following are examples of ID numbers with the alpha prefix highlighted:

ABC1234567

ABC1234H567

ABCD1234H567

ABCD1234H56789012

BCBS alpha prefix

Note : Guest members do not have an alpha prefix. They are identified by “Guest Member” on their health plan ID card.

Blue cross Blue Shield association cannot accept Guest Membership claims electronically. They must be sent hard copy. However, fax submission is allowed at the  ollowing fax numbers: 866-365-5504 or 303-764- 7123 for BCBS OF CA AND BCBS OF CO

EMPIRE BCBS Decides the pre certification requirements based on the prefix id.

Prefixes for Empire HMO Plans

Precertification remains the responsibility of the provider for all Empire HMO network members. HMO products include BlueChoice HMO, Direct Connection HMO, Child Health Plus, BlueChoice HMO/POS and Direct POS. Please refer to the member’s ID card to determine if he/she has one of these products.

BJF NCJ YLB YLG YLX BJT RFB YLC YLK YLY EHP SWH YLD YLN YLZ MES YLA YLE YLW 

Medicare Advantage Member Identification Prefixes Updated for 2015

Empire BlueCross moved Individual (non-group) Medicare Advantage members to a single claims processing system Jan. 1, 2015. Member identification prefixes were updated as part of that transition. The 2015 member identification prefixes for individual Medicare Advantage plans are listed below.

Prefix State/Area Plan Type Plan Name Provider and member service CMS contract

VOF NY MA HMO MediBlue HMO 1-800-499-9554 H3370

VOG NY MA PPO MediBlue PPO Plus 1-866-395-5175 H3342

Premera Blue Cross & The Regence Group Common Alpha Plan Prefixes Last updated: 09/01/2016

• Premera Blue Cross & Premera Blue Cross/NASCO Prefixes

• Western WA providers submit claims to Regence Blue Shield. Eastern WA and Alaska providers submit to Premera.

• Prefixes with * include all characters for the 3rd position unless otherwise listed

https://www.premera.com/documents/020469.pdf

BCNEPA Plan and Alpha Prefix Guide

Below you will find a list of the 2015 BCNEPA plans with the corresponding Highmark Blue Cross Blue Shield plans for 2016. As members renew or enroll their individual or group contracts for health care coverage in 2016, they will be presented with a new Highmark branded ID card. Verify eligibility via Highmark’s NaviNet. Note: Some members will remain in Blue Cross of Northeastern Pennsylvania health plans until their coverage renews to Highmark health plans later this year.

Claims filing information and provider service phone numbers are available in the December, January and February Provider Bulletins.

https://www.bcnepa.com/Providers/providerrelations/ReferenceGuides/AlphaPrefixList.pdf

Blue Cross and Blue Shield of Illinois (BCBSIL) members’ ID  cards in the BlueCare Direct and Blue Choice Preferred PPO plans have been updated. Below is a list of the old and new alpha prefix codes.

Network Name Old Alpha Prefix New Alpha Prefix

BlueCare Direct 

YDQ – Retail ON Exchange

YDO – Retail OFF Exchange

YDV – SG ON Exchange

YDM – SG Off Exchange

QMD – Retail ON Exchange

QMC – Retail OFF Exchange

QMB – SG ON Exchange

QMA – SG OFF Exchange

Blue Choice Preferred

PPO YDX – Retail ON Exchange

YDW – Retail OFF Exchange

YUV – SG ON Exchange

YDZ – SG OFF Exchange

QMF – Retail ON Exchange

QME – Retail OFF Exchange

YUV – SG ON Exchange

QMG – SG OFF Exchange

TIPS FOR SUCCESS

Always use the alpha prefix on the member’s current ID card. If there is no alpha prefix, do not create one or use an alpha prefix from another member’s ID card, even one from the same BCBS Plan. Doing so may cause delays in the handling of your inquiries and claims. If the card presented has no alpha prefix, follow the instructions on the back of the ID card for inquiries and claim handling.

Note : We have added some more prefixes in the list. Please use comment section to add or Modify further.