HealthCare News

Claims Filing Rules For Counties Bordering North Dakota

Issue: #404 NOV2018

Topic: Education


This is a reminder of claim filing rules for providers located in counties of states that border North Dakota (Minnesota, Montana and South Dakota).

Example:

  • Dr. Smith is located in MN and has no contract with MN.
  • Dr. Smith has a contiguous area contract with ND.
  • Dr. Smith files a claim to ND for a ND member who resides or works in ND. It is a local ND in-network claim.
  • Dr. Smith files a claim for a MN member to MN. It is a local MN out-of-network claim.
  • Dr. Smith files claims to MN for IL member or ND member who doesn’t reside or work in ND, regular BlueCard claim filing rules apply. It is a BlueCard out-of-network claim.

Example:

Provider is located in both service areas and has contracts with plans in both service areas.

  • Dr. Smith has an office in ND in an area contiguous to SD and an office in SD in an area contiguous to ND.
  • Dr. Smith has a contract with ND;
  • Dr. Smith has a contract with SD.
  • Dr. Smith sees a ND member in his ND office. The claim is filed to ND. It is a local ND in-network claim.
  • Dr. Smith sees a SD member who resides or works in SD in his ND office. The claim is filed to SD. It is a local SD in-network claim.
  • Dr. Smith sees a SD member, not residing or working in SD, in his ND office. The claim is filed to ND; regular BlueCard claim filing rules apply. It is a BlueCard in-network claim.
  • Dr. Smith sees a SD member who resides or works in SD in his SD office. The claim is filed to SD. It is a local SD in-network claim.

The exceptions to these rules apply to health care providers for lab, durable medical equipment, medical supplies and specialty pharmacy. Providers can reference the BlueCard Provider Manual for more information.

www.BCBSND.com/documents/10476/35337/wcmp_042145_blue_card_manual