HealthCare News

BlueCard Ancillary Claims

Issue: #399 JAN2018

Topic: Coding/Billing


Blue Cross Blue Shield of North Dakota (BCBSND) will return claims for ancillary services filed to the incorrect plan.

Generally, health care providers file claims for Blue Cross and Blue Shield (BCBS) patients to the local Blue plan. However, in unique circumstances, claims filing directions differ based on the type of provider and service.

Ancillary claims incurred by a participating provider in a contiguous county may be filed directly to the local plan, but solely for members who live or work in this service area. Claims for all other members must be filed as defined for ancillary services.

Ancillary providers are Independent Clinical Laboratory, Durable/Home Medical Equipment and Supplies, and Specialty Pharmacy providers. The local Blue plan for ancillary services is defined as follows:

Independent Clinical Laboratory (Lab): The plan in the state where the specimen was drawn. Where the specimen was drawn will be determined by the state where the referring provider is located.

Durable/Home Medical Equipment and Supplies (DME): The plan in the state where the equipment was shipped to or purchased at a retail store. “Shipped to” takes priority over where the equipment was purchased. The Place of Service (POS) will identify where the claim should be filed:

  • 12 (home), 04 (homeless shelter), 09 (prison), 13 (assisted living), 14 (group home), 34 (hospice), 55 (residential substance abuse treatment facility) – File to the plan in the state where the item was shipped to.
  • 11 (item was received in the provider’s office) – File to the plan in the state where the provider is located.
  • 17 (item was purchased at a retail location) – File to the plan in the state where the retail provider is located.

Specialty Pharmacy: The plan in the state where the ordering physician is located.

This policy does not apply to the Federal Employee Program (FEP).

Provider typeHow to file (required fields)Where to fileExample
Independent Clinical Laboratory
(any type of non-hospital-based laboratory)

Types of Service include but are not limited to: blood, urine, samples, analysis, etc.
Referring Provider:

Field 17B
on the CMS-1500 Health Insurance Claim Form or
Loop 2310A (claim level) on the 837 Professional Electronic Submission
File the claim to the plan in the state where the specimen was drawn.

Where the specimen was drawn will be determined by the state where the referring provider is located.
Blood is drawn in a lab or office setting located in North Dakota and referring provider is located in North Dakota.

Blood analysis is done in Minnesota.

File to:
Blue Cross Blue Shield of North Dakota (BCBSND), the state where
the referring provider is located.

Claims for the analysis of a lab must be filed to the plan in the state where the specimen was drawn. Where the specimen was drawn will be determined by the state where the referring provider is located.
Durable/Home Medical Equipment
and Supplies (D/HME)

Types of service include but are not limited to: hospital beds, oxygen tanks, crutches, etc.
Patient's Address:

Field 5 on the CMS 1500 Health Insurance Claim Form or
Loop 2010CA on the 837 Professional Electronic Submission
Ordering provider:

Field 17B on the CMS-1500 Health Insurance Claim Form or
Loop 2420E (line level) on the 837 Professional Electronic Submission
Place of service:

Field 24B
on the CMS-1500 Health Insurance Claim Form or
Loop 2300, CLM05-1
on the 837 Professional Electronic Submission
Service facility
location information:

Field 32 on the CMS-1500 Health Insurance Form or
Loop 2310C (claim level) on the 837 Professional Electronic Submission
File the claim to the plan in the state where the equipment was shipped to or purchased in a retail store.

The "shipped to" location takes priority over where the equipment was purchased.

Example: If the equipment is purchased in Minnesota and shipped to North Dakota, file the claim to North Dakota.

If the equipment is purchased in Minnesota and the member leaves the retail store with the product, submit the claim to the Minnesota plan.
a) Wheelchair is purchased at a retail store in North Dakota.

File to: BCBSND

b) Wheelchair is purchased on the internet from an online retail supplier in Minnesota and shipped to North Dakota.

File to: BCBSND

c) Wheelchair is purchased at a retail store in Minnesota and shipped to North Dakota.

File to: BCBSND

d) Wheelchair is purchased at a retail store in Minnesota and the member leaves the store with it.

File to: Minnesota
Specialty Pharmacy

Types of service: non-routine, biological therapeutics ordered by a health care professional
as a covered medical benefit as defined by the member Plan’s Specialty Pharmacy formulary. Includes but
is not limited to: injectable, infusion therapies, etc.
Referring Provider:

Field 17B on the CMS-1500 Health Insurance
Claim Form or
Loop 2310A (claim level) on the 837 Professional Electronic Submission
File the claim to the Plan in the state where the ordering physician is located.Patient is seen by a physician in North Dakota who orders a specialty pharmacy injectable for the patient. Patient will receive the injections in Arizona, where the member lives for six months of
the year.

File to: BCBSND

The ancillary claim filing rules apply regardless of the provider’s contracting status with the Blue plan where the claim is filed.

Providers are encouraged to verify member eligibility and benefits by calling the phone number on the back of the member ID card, or 800-676-BLUE, prior to providing any ancillary service.

Providers that utilize outside vendors to provide services (example: sending blood specimen for special analysis that cannot be done by the lab where the specimen was drawn) should utilize in-network participating ancillary providers to reduce the possibility of additional member liability for covered benefits. Contact BCBSND for a list of in-network participating providers.

Members are financially liable for ancillary services not covered under their benefit plan. It is the provider’s responsibility to request payment directly from the member for non-covered services.