Identifying bcbs alpha prefix -Suitcase Logo

How to Identify BlueCard Members

When out-of-area BCBS members arrive at your facility, be sure to ask them for their current membership ID card. The two main identifiers for BlueCard members are the alpha prefix and a “suitcase” logo.

Alpha Prefix

The three-character alpha prefix of the member’s identification number is the key element used to identify and correctly route out-of-area claims. The alpha prefix identifies the Blue Plan or the national account to which the member belongs.

There are three types of alpha prefixes: plan-specific, account-specific and international:

1. Plan-specific alpha prefixes are assigned to every BCBS Plan and start with X, Y, Z or Q. The first two positions indicate the Plan to which the member belongs while the third position identifies the product in which the member is enrolled.

2. Account-specific prefixes are assigned to centrally-processed national accounts. National accounts are employer groups with offices or branches in more than one area, but offer uniform coverage benefits to all of their employees. Account-specific alpha prefixes start with letters other than X, Y, Z or Q. Typically, a national account alpha prefix will relate to the name of the group. All three positions are used to identify the national account.

3. Occasionally, you may see ID cards from foreign BCBS members. These ID cards will also contain three-character alpha prefixes. For example, “JIS” indicates a Blue Cross and Blue Shield of Israel member. The BlueCard claims process for international members is the same as that for domestic BCBS members.

ID cards with no Alpha Prefix

Some ID cards may not have an alpha prefix. This may indicate that the claims are handled outside the BlueCard Program. Please look for instructions or a telephone number on the back of the member’s ID card for information on how to file these claims. If that information is not available, call Provider Services at 1-800-922-8866.

“Suitcase” Logo

BlueCard PPO offers members traveling or living outside of their Blue Plan’s area the PPO level of benefits when they obtain services from a provider or hospital designated as a BlueCard PPO provider. Members are identified by the “PPO in a suitcase” logo on their ID card.

Providers should verify benefits for HMO members. The empty suitcase logo does not guarantee that the HMO member has benefits if they see a participating provider in that state. Most HMO members must get an authorization to see a provider outside of their service area. To ensure claims are paid timely and accurately, please use iLinkBLUE or call Provider Services at 1-800-922-8866.


HMO patients serviced through the BlueCard® Program

In some cases, you may see BCBS HMO members affiliated with other BCBS Plans seeking care at your facility. You should handle claims for these members the same way you handle claims for Blue Cross and Blue Shield of Louisiana members and BCBS PPO patients from other Blue Plans — by submitting them through the BlueCard Program. Members are identified by the “empty suitcase” logo on their ID card.

BlueCard members throughout the country have access to information about participating providers through BlueCard Access, a nationwide toll-free number 1-800-810-BLUE (1-800-810-2583) that allows us to direct patients to providers in their area. Members call this number to find out about BlueCard providers in another Blue Plan’s service area. You can also use this number to get information on participating providers in another Blue Plan’s service area.

Coding a Facility Claim Procedure, Modifier and Diagnosis Codes - Basic steps

 -    A critical element in claims filing is the submission of current and accurate codes to reflect the services provided. Correct coding is essential for correct reimbursement. We have applied procedure code edits to outpatient claims for our Medicare Advantage members since 2008. Effective September 15, 2012, wewill apply these edits to our Commercial outpatient claims.

Complete and accurate procedure code, modifier and diagnosis code usage at the time of billing ensures accurate processing of correct coding initiative edits. Wecan only use the primary modifier submitted with the alternate procedure code for outpatient billing. We encourage you to purchase current copies of CPT, HCPCS and ICD code books.

The correct coding initiative edits and medically unlikely edits will apply to outpatient claims from the following hospitals and facilities:

• Acute care hospitals

• Long term acute care hospitals

• Ambulatory surgical centers

• Psychiatric facilities

• Substance abuse facilities

• Inpatient rehabilitation facilities

• Skilled nursing facilities

Note: Ambulatory surgical centers will follow institutional correct coding initiative edits forour commercial business, while our Medicare Advantage business will process against the professional edits.

Unlisted Procedure Codes

Unlisted procedure codes are not recommended for outpatient claims since they impact reimbursement of the claim. Refer to the outpatient payment programs section of this manual and the participation agreement for coding and reimbursement instructions.

Code Updates

The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) update procedure codes to reflect changes in health care and medical practices. Coding updates occur quarterly with the largest volume effective January 1, of each year. Current Procedural Terminology (CPT) and Healthcare Common Procedure Code System (HCPCS) codes may be added, deleted or revised with each update. International Classification of Diseases-9th Revision-Clinical Modification (ICD-10-CM) updates may occur bi-annually, with the largest volume effective October 1 of each year.

Modifiers

A modifier allows a provider to indicate that a service or procedure is altered by some specific circumstance, but the definition or code is not changed. Modifiers may be used in some instances when additional information is needed for proper payment of claims. Valid modifiers and their descriptions are found in the most current CPT and HCPCS coding books.

Weprocess claims using only the first modifier for outpatient institutional claims. While up to three modifiers are accepted, claims are processed using only the first modifier. Therefore, submit the most important modifier affecting reimbursement in the first position on paper and electronic claims.

Note: If your claim is denied due to a lack of documentation to support the use of a specific modifier, you may submit an appeal. Your appeal must be submitted in writing and accompanied by the necessary documentation. 4

Modifiers may be used to indicate that:

• A service or procedure has been increased or reduced

• Only part of a service was performed

• A bilateral procedure was performed

• A service or procedure was provided more than once

• Unusual Events Occurred

Coding tips for Diagnostic Imaging and Laboratory codes

Diagnostic Imaging

If the treating chiropractic provider refers the reading or interpretation of a radiology service to a radiologist, reimbursement for the professional component of that service will only be made to the radiologist, and the treating chiropractic provider should not bill for that component.

Component Modifier Description of Services

• Professional 26 Services rendered by a licensed practitioner to perform the diagnostic interpretation of each study. It is required to document the diagnostic conclusions of the study by a written and signed radiology report.

• Technical TC Radiology services that include providing the facilities, equipment, resources, personnel, supplies and support needed to perform and produce the diagnostic study.

• Global N/A Combines both the technical and professional components in the service provided.

Laboratory

BlueCare, BlueMedicare HMO, BlueMedicare PPO and BlueOptions members covered in-office laboratory services are restricted to:

81000, 81001, 81002, 82947, 82948, 85014, 85025 All other laboratory services should be referred to Quest Diagnostics, Inc.

For BlueChoice and Traditional members, members may be referred to any Florida Blue contracted laboratories, including Quest Diagnostics.

Laboratory services for select health and musculoskeletal conditions may comprise one or more of the procedure codes on the list of in-office laboratory codes. Reimbursement for routine venipuncture for collection of specimen (36415) is only payable when paired with modifier 90 and when the laboratory sample is drawn in the chiropractor’s office, but the sample is sent to an offsite laboratory for processing

Florida Blue submitting secondary claim address

Filing the Medicare Cross-Over Claim

File the claim to your Medicare carrier for primary payment. Claim information will not be crossed over to the member’s supplement plan (the secondary payer) until after Medicare has processed the claim and released it from the Medicare payment hold. Medicare secondary claims will normally be electronically forwarded by GHI (the CMS vendor) directly to the member’s supplement Blue Plan for processing of the secondary benefits. Check the Medicare Remittance Notice to identify whether the claim was crossed over directly to the member’s Medicare supplement Blue Plan. If it did, you do not need to take further action. The paper remittance notice will state “Claim information forwarded to: (Name of secondary payer). “ The 835 (electronic remittance) record can also carry the secondary forwarding information.

You will receive payment or processing information from the member’s supplement plan after they receive the Medicare payment. Please allow 45 days from the Medicare payment date for the secondary claim (Medicare Supplement coverage) to process.

If the claim did not crossover electronically to the secondary payer (Medicare supplement plan), then file the claim to BCBSF with the Medicare Remittance Notice attached. Send the claim to:

Florida Blue P.O. Box 1798 Jacksonville, Florida 32231-0014

Do not send secondary claims directly to the member’s Blue Plan secondary payer.

Note: If more than one claim appears on the Medicare Remittance Notice, please indicate the specific claim you are filing.

Inquiries around Medicare Crossover Claims

Direct inquiries on secondary claims to Florida Blue unless the member’s Blue Plan have requested specific information from you on a particular claim. Inquiries received on secondary claims by BCBSF will be coordinated with the member’s Blue Plan for resolution.

Example: A provider received the primary Medicare payment. The Medicare Remittance Notice stated, “Claims information was forwarded to: (Name of secondary payer).” It has been 45 days since Medicare’s payment and no communication has been received from the member’s supplement plan. This should be sent to Florida Blue as an inquiry so the member’s Blue Plan can be contacted and a resolution made on the status of the secondary claim. Florida Blue will communicate the resolution back to the provider. 13

Tips for Filing Inquiries, Corrected Claims and Provider Appeals from BCBS

Inquiries

When submitting an inquiry regarding corrected claims, questions about late charges, medical records or other situations, remember to complete the Provider Claim Inquiry Form and attach it to your claim. You should use this form for claims that denied with reason code CADEV (contest/additional information) and INFNR (claim denied, requested information not received or incomplete.) Please do not submit these denials with a Provider Appeal form.

A corrected claim is a claim that has already been processed, whether paid or denied, and is resubmitted with additional charges, different procedure or diagnosis codes or any information that would change the way the claim originally processed.

For a copy of the Provider Claim Inquiry Form Click Here, or visit our website at www.floridablue.com, select the Providers tab, then Tools & Resources.

Filing Corrected Claims

When submitting a corrected claim, follow these steps:

• Submit a copy of the remittance advice with the correction clearly noted.

• If necessary, attach requested documentation (e.g., nurses’ notes, pathology report) along with the copy of the remittance advice. To ensure documents are readable, do not send colored paper or double-sided copies.

• Boldly and clearly mark the claim as “Corrected Claim.” Failure to mark your claim appropriately may result in rejection as a duplicate.

• Attach the completed Provider Claim Inquiry Form with your corrected claim.

• If a modifier 25 or 59 is being appended to a procedure code that was on the original claim, do not submit as a "Corrected Claim." Instead, submit as a coding and payment rule appeal with the completed Provider Appeal Form and supporting medical documentation (e.g., operative report, physician orders, history and physical).

How to Avoid Provider Identification Errors on Claims

Florida Blue recently made several changes to our claims processing system to comply with HIPAA 5010 requirements. In February 2012, process enhancements were made to ensure that a provider’s National Provider Identifier (NPI) and Tax ID number are matched appropriately.

We have seen an increase in the volume of provider correctable error codes that cause claim processing delays. Below are reminders to help you reduce the number of WEBV040 and WEBV042 claims processing errors displayed when claim data (or information) does not match information registered with Florida Blue

Billing Provider Section

This section is used to provide information regarding the billing provider for services rendered. It should match the name written on the check or electronic funds transfer from Florida Blue.

• OPTION 1: If you are registered as a group provider (PA, LLC, etc.) with Florida Blue and you want to bill as a group provider, enter the appropriate group name, Tax ID number and the group NPI (type 2).

− THE MATCH: Group Name matches Group NPI matches Group Tax ID

Overpayment Recovery Program - BCBS FLORDIA update

Effective February 27, 2012, Blue Cross and Blue Shield of Florida, Inc. (BCBSF) will implement additional changes to our Overpayment Recovery Program. These changes relax certain netting rules so our claims system can net (offset) overpaid funds quicker and more efficiently. Our new netting rules should make it easier for providers to reconcile accounts when it is necessary for BCBSF to recoup overpaid amounts.

Netting Across Lines of Business

• BCBSF will now offset overpaid amounts across different lines of business. In the past, because of  system limitations, BCBSF was limited to offsetting against the same type of claims only (e.g., State   Group, Federal Employee Program (FEP), etc.) However, our claims system will always attempt to  recover overpaid funds from claim payments for the same line of business first before netting from a

different line of business.

• There is no change to remittance advice data. You will see the same claims data that you see today.

Netting Across Different Addresses

• BCBSF will now offset overpaid amounts across different addresses (provider locations.) In the past,    we did not offset against different locations (addresses) operated by the same provider or physician   group. However, effective February 27, 2012, we will offset against another address if funds are not  available from the provider address (location) that was overpaid.

• The remittance advice will show details including the impacted provider name, provider number and claim(s) information to assist in reconciling accounts.

 Overpayment Disputes

• BCBSF may offset the portion of an overpayment that is not in dispute.

Example: BCBSF overpaid Dr. Jones $500. However, Dr. Jones disputes $300 of the overpayment. BCBSF may net (offset) the $200 amount not in dispute to go toward the overpaid amount, even if the dispute is not resolved.

Additional Information

• Providers may experience netting more frequently, because our processes expedite recovery of overpaid funds.

• To avoid netting, you must submit a payment to BCBSF within 40 days from the original request   refund (invoice) letter date, along with a copy of BCBSF’s request refund letter.

• If you do not submit the overpaid amount to BCBSF within 40 days, BCBSF will begin the netting    process.

Update on Evaluation Management CPT codes - HighMark insurance

Highmark Announces Adjustments to UCR and Premier Blue sm Shield Reimbursement

 As noted in the April 2011 issue of PRN, Highmark filed with, and has now received approval from, the Pennsylvania Insurance Department to implement a broad range of UCR Level II and Premier Blue Shield reimbursement adjustments.

The adjustments impact anesthesia, select surgical, diagnostic and evaluative services, including, but not limited to, musculoskeletal, eye, behavioral health, allergen immunotherapy and routine electroencephalography procedures.

• Increases in allowance will be implemented for dates of service beginning July 1, 2011.

• A minimum number of allowances will be decreased for dates of service on/after Sept. 26, 2011.

Highmark will also implement changes to its payment differential for evaluation and management procedure codes 99201 through 99215 when performed in the facility, compared to services performed in a non-facility setting. Effective Sept 26, 2011, Highmark will calculate payment for the facility service using Medicare's site-of-service differential, or at a predetermined cap, not to exceed a certain designated percentage. Currently, Highmark applies a 15 percent differential.

In addition, the allowances for CT studies of the abdomen and pelvis combined, procedure codes 74176, 74177 and 74178,will be increasing with this update. The allowances will be based upon additional data collection and analysis and have yet to be finalized.

Adverse Determination External Review Process

 The Adverse Determination External Review process will provide for an Independent Review Organization (IRO), to resolve disputes with physicians and physician groups arising from BCBSF’s determination that certain services provided to BCBSF’s members are not covered services because they are not medically necessary, experimental or investigational in nature, supportive of an experimental or investigational procedure, or supportive of a not medically necessary procedure (“Adverse Determination Disputes”). The external review process is only available if BCBSF makes the Adverse Determination and administers its Plan Member appeals and/or external review process. Additionally, the Adverse Determination External Review Process is only available if BCBSF upholds its initial Adverse Determination through the internal Post-Service Appeals process and the cost of the service at issue exceeds the threshold amount, if any, the BCBSF’s Plan member would need to satisfy in order to seek external review under the terms of the applicable health benefit plan. 

Pre service and post service Adverse Determination Appeals

 Adverse Determination Appeals

A provider may file a written request with BCBSF for reconsideration of a denial of payment because a proposed, or actual, health care service or supply was not medically necessary, was experimental or investigational, was supportive of an experimental or investigational, or was supportive of a not medically

necessary procedure (“Adverse Determination Appeal”). An Adverse Determination Appeal can be of pre-service claims or a post-service claim if the requirements outlined below are met. An Adverse Determination appeal must be in writing and is not triggered by claim status requests or telephone inquiries regarding the application of benefits or allowed amount.

Pre-Service Adverse Determination Appeals

A physician (i.e., Medical Doctor or Doctor of Osteopathy) or physician group can appeal a pre-service

Adverse Determination (Pre-Service Appeals), if they are appealing on behalf of a BCBSF member. Except for urgent Pre-Service Appeals, authorization must be obtained from the BCBSF member in writing. Pre-Service appeals will be handled by BCBSF under the appeal process available to its member based on the terms of that member’s contract or policy and the applicable state and federal laws and regulations.

Utilization Management Appeals - bcbs

A Utilization Management (UM) Appeal is defined as a written request from a provider to review a claim that required an authorization or precertification affecting a claim’s payment. This does not include provider appeals of pre-service determinations (unless required under ERISA), claims status requests, telephone inquiries or post-service claims review regarding the application of benefits or allowed amounts.

UM appeals must be filed pursuant to the timeliness requirements of the applicable Agreement with BCBSF or within five years from payment date. BCBSF will not overturn administrative claim denials based on the provider’s failure to comply with required procedures and time frames. UM appeals should be sent to the address below with the following information:

• The completed Provider Appeal Form (available at www.bcbsfl.com).

• A copy of the remittance advice.

• The necessary medical documentation (e.g., operative report, physician orders, etc.) as indicated by the reason for the reduction or the denial on the remittance advice.

Billing Dispute External Review Process

The Billing Dispute External Review Process (BDERP) will provide for a Billing Dispute External Reviewer

(BDER), to resolve disputes with physicians and physician groups arising from covered services provided

to BCBSF’s members by such physicians and/or physician groups concerning:

• For Coding and Payment Rule appeals finally adjudicated on or after August 21, 2008, BCBSF’s application of BCBSF’s coding and payment rules and methodologies for covered fee for service

claims (including any bundling, downcoding, application of a CPT modifier, and/or other reassignment of a code by BCBSF) to patient specific factual situations, including without limitation the appropriate  payment when two or more CPT codes are billed together, or whether a payment enhancing modifier is appropriate. All such Billing Disputes must be submitted to the BDER no more than 90 calendar days after a physician or physician group exhausts the internal appeal process, except the parties have agreed that for appeals finally adjudicated after August 21, 2008 and before November 21, 2008, the date the BDERP will start accepting claims, the physicians and physician groups will have until December 20, 2008 to submit their eligible billing disputes. For calculation purposes, the start date will be the date on the appeal letter and the ending date will be when a Billing Dispute is received by the BDER.

BCBS Coding and Payment Rule Appeals

Coding and Payment Rule Appeals

A Coding and Payment Rule Appeal is a written request from a licensed health care practitioner for

reconsideration of a health care claim based on BCBSF’s application of its coding and payment rules and

methodologies (including without limitation any bundling, downcoding, application of a CPT modifier,

and/or other reassignment of a code by BCBSF). These appeals apply to claims filed by M.D.s and D.O.s

in connection with health care services rendered to a specific individual covered under a policy or plan

insured or administered by BCBSF. A Coding and Payment Rule Appeal does not refer to pre-service

review, concurrent review, claim status requests, and other types of provider communication, such as

telephone inquiries.

Claims processed after the implementation date, regardless of service date(s), will process according to

the updated version. No retrospective claim payment changes are made for processing changes that are

the result of new code editing rules.

When provider can appeal and four type of appeal

Provider Appeals

Providers may request reconsideration of how a claim processed, paid or denied. These requests are

referred to as appeals.

There are four different types of appeals:

• Coding and Payment Rule Appeals

• Utilization Management Appeals

• Adverse Determination Appeals

• All Others

Filling prescription drug - points to consider - what to do patient left ID card

BCBS - Prescription Drugs

What should I consider before I fill a prescription drug? 

Here are few things to keep in mind before you fill a prescription drug. 

• Use a participating pharmacy and Preferred Generic drugs (when available) to lower your cost (see your cost now by using our Drug Pricing tool).   Using mail-order for ongoing maintenance medication may also save you money.

• Some drugs may require your doctor to submit a prior authorization before they’re covered (See drugs that may require Prior Authorization in our Medication Guide).

• Some drugs may be limited in the amount you can fill within thirty days, unless a special approval is obtained (see the Responsible Quantity Program in our Medication Guide).

• For plans that cover brand name drugs, certain brand name drugs may not be covered or will cost you more unless you have tried the generic alternative first (see the Responsible Steps Program in our Medication Guide).

• Many specialty drugs require a Prior Authorization and must be purchased from our Specialty Pharmacy network, Caremark to pay the lowest amount.  Call Caremark at 1-866-278-5108 for more information (see more about Specialty Drugs in our Medication Guide).   

IMPORTANT NOTE: Not all health plans come with pharmacy coverage and coverage varies by plan. If you’re part of an employer group, your employer may provide prescription drug benefits through another company. Please refer to your Benefit Booklet for coverage details, limitations and exclusions.    

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.

Urgent care and emergence room - payment different Emergency Care - BCBS

Will the amount I pay be different if I go to an urgent care center vs. an emergency room?

Benefits vary by plan, but typically your co-pay will be lower if you visit an urgent or ambulatory care center. Whenever possible, you should avoid hospital emergency rooms unless the emergency is life threatening. View Current Benefits located under the Benefits menu.

When should I go to an urgent care center (walk-in clinic) vs. an emergency room?

     For non-emergency assistance, urgent care centers (also called ambulatory care centers) provide prompt, quality service. They are staffed with qualified doctors and nurses who can handle medical problems like cuts and colds, flu symptoms, minor fractures, sprains and burns, ear infections, allergic reactions, animal bites, sprains and even immunizations.

     In a medical emergency—including shortness of breath, severe abdominal or chest pains, uncontrolled bleeding, loss of consciousness, changes in vision, severe vomiting or other life-threatening condition—call 911 or visit the nearest hospital emergency room.