User Guide — BCBS Claim Routing and Special Handling (2024)

athenahealth uses the member ID prefix as well as the BlueCard logo on the member's insurance card to identify patients enrolled in the BlueCard program.

Effective April 15, 2018, BCBS prefixes are alpha only or a combination of alpha and numeric characters. The prefixes have at least one alpha character, do not contain only numbers, and do not include the numbers 1 or 0 in any position, for example, AAA, A2A, 2AA, 22A, AA2, 2A2, A22.

1. Use the member's prefix on the BlueCard to select the correct Home Plan package on the Claim Edit page or in the patient Quickview. This will ensure the claim is being evaluated against the correct logic.
2. Choose the accurate credentialing status for the rendering provider on the Payer Enrollment page; this information plays a vital role in the routing process. You can check the credentialing status at any time on the Provider Credentialing page.
3. Select a non-BlueCard/FEP BCBS package as the home plan if the patient does not have a BlueCard/FEP policy.

1. Display the Claim Edit page for the claim. You can use the Find Claim tool to locate the claim.
2. Medicaid Resubmission —
   1. Code: — Enter 7.
   2. Original Ref. No: — Enter the BCBS-MS claim number from the EOB or RA.
3. Change Status — Select DROP.
4. Click Save Claim.

Note: You should submit a BCBS-MS void only for a paid claim where you are requesting that BCBS-MS take back their payment.

1. Display the Claim Edit page for the claim. You can use the Find Claim tool to locate the claim.
2. Medicaid Resubmission —
   1. Code: — Enter 8.
   2. Original Ref. No: — Enter the BCBS-MS claim number from the EOB or RA.
3. Change Status — Select DROP.
4. Click Save Claim.
   Note: BCBS-SC cannot accept void-only claims electronically.

• Credentialing status — The Participating or Not Participating status of the rendering provider, which determines whether to route claims to the home plan or to a local plan. This status does not apply to the medical group. When there is no Payer Enrollment row or there is a Payer Enrollment row but no value in the row for the rendering provider, by default the system considers that the rendering provider is Non-Participating with that respective home plan for routing purposes.
• Home payer — The BCBS payer that owns and operates the patient's plan. This information appears on the member ID card.
• Local payer — The BCBS payer that provides coverage in the state of the "Patient Department" selected on the claim; where services are rendered. This Department State field is used to identify the local payer.
• Routing program — The BCBS program intended for the selected insurance package. Routing programs are found in every insurance package with the values of "BlueCard," "FEP," or "None." Routing logic will not occur if the selected package program is set to "None."
• Member ID prefix — The first three characters (alpha and alphanumeric) of a BCBS member ID defines the patient's home plan.

For BlueCard and FEP programs, if the place of service indicated on the claim equals Home (12), all BCBS routing logic is overridden and the claim is always submitted to the patient's residence state.

BlueCard

• Participating Credentialing Status — If the rendering provider for the medical group/department and insurance package selected on a claim is set to Participating on the Payer Enrollment page, athenaOne routes the BCBS claim to the insurance package on the claim.
• Not-Participating Credentialing Status — If the rendering provider for the medical group/department and insurance package selected on a claim is set to Not-Participating on the Payer Enrollment page, athenaOne routes the BCBS claim to the BCBS plan of the department.

FEP (Federal Employee Program)

• FEP routing program functions irrespective of the rendering provider's credentialing status on the Payer Enrollment page with patient's home plan (selected insurance package in the claim). The FEP routing logic sends the claim to the local BCBS payer based on the department's state.

None

• Regardless of the package's program owner (even if affiliated with BCBS), a package with "None" set as the routing program is routed to the selected payer without global routing logic firing on the claims.

BCBS routing (BlueCard/FEP) in the state of New York is determined by the rendering provider credentialing status with the patient's home plan (on the Payer Enrollment page) and the county where the service department address is located.

Because some New York counties have overlapping contracts with more than one BCBS-NY administration, there is sometimes more than one local BCBS payer.

When a practice in New York adds a new department or updates existing departments, athenaOne automatically checks the county where the ZIP code of the department is located.

If the county is one of the overlapping counties, once the practice has saved the created or updated department, a new BCBS-NY Local Payer field appears. Your practice must then click the Update link and select the appropriate local BCBS plan, because this information can be obtained only through their provider relations representative for that county.

There are a few additional complex regions where you can expect some BCBS routing issues due to those states having multiple BCBS contractors. The following states are affected by these complex routing scenarios for global routing:

• PA
• VA/DC/MD
• KC/KS
• ID
• WA
• CA

Denial issues can still occur through this global routing process.

• If you receive a denial, and you determine that the correct home plan package for the patient's policy is selected on the Claim Edit page and that the correct credentialing status is selected on the Payer Enrollment page, athenahealth recommends that you kick the claim with CSTROUTING. This sends the claim to athenahealth to determine why the routing did not function appropriately.
• If you see a claim that has a current error of CSTROUTING, athenahealth is already researching the error.