The BlueCard Program allows participating Blue Plan providers in every state to submit claims to their local Blue Plan for indemnity, PPO and managed care patients who are enrolled in an out-of-area Blue Plan.
Provided below are selections with information that can assist your office with questions you may have about the BlueCard Program.
Medical Policy and Pre-Certification/Pre-Authorization Router for Out-of-Area Members
- This is a router that will show the Medical Policy and Pre-certification/Pre-authorization Information for Out-of-Area Members. All you need is the out-of-area member's alpha prefix and you can find their home plan's medical policy and pre-cert/pre-auth information.
BlueCard® is a registered trademark of the Blue Cross and Blue Shield Association, an association of independent health plans.
Electronic Provider Access (EPA) for Pre-Service Review
Background: The Blue Cross and Blue Shield Plans launched a new tool on January 1, 2014, that gives providers the ability to access out-of-area member’s Blue Plan (Home Plan) provider portals to conduct electronic pre-service review. Electronic Provider Access (EPA) will enable providers to use their local Blue Plan provider portal to gain access to an out-of-area member’s Home Plan provider portal, through a secure routing mechanism. Once in the Home Plan provider portal, the out-of-area provider will have the same access to electronic pre-service review capabilities as the Home Plan’s local providers.
Definition Pre-Service Review: The term pre-service review is used to refer to pre-notification, pre-certification, pre-authorization and prior approval, amongst other pre-claim processes.
EPA will give out-of-area providers access to the member’s Home Plan portal, through local Blue Plan portals, to conduct pre-service review. The provider will continue to use the local Blue Plan portal, following the local plan's authentication process. As a Highmark Delaware provider, you will initiate this process via NaviNet's Authorization Submission transaction by selecting the option Pre Service Review for Out of Area Members.
Medical Records: Tips to Improve Processing
The member's home plan may request Highmark obtain medical records from you. The request will come to you in the form of a letter.
Highmark will mail the letter to address on your Highmark file unless you have provided us with an alternate address to send records on a past request.
You can expedite the process by following these simple guidelines:
- Promptly fax the records requested, along with the letter sent to you.
- The letter serves as the fax cover sheet. Please fax it as the first document followed by the records/documentation.
- If you receive multiple letters, treat each separately and fax separately. This speeds up the process of getting the records to the member’s plan to finalize the claim.
- If you are the rendering physician and do not have the requested records, please notate this on the letter with the name of the referring physician and address or phone number.
- If you lose the letter and it is required, please call customer service and we will fax a new one; otherwise, you can fax the documentation and include the fax cover sheet with the patient’s identification number and claim number.
Last updated on 10/11/2022 4:32:50 PM