• Overview

• Defining what Plan is local

• Examples of how claims will be processed

• Ancillary providers contracting options
• Use contracted ancillary providers
• Claims submission guidelines
• Specialty pharmacy

Overview

Effective Oct. 14, 2012, Wellmark Blue Cross and Blue Shield is implementing the clarified ancillary claims filing rules released by the Blue Cross and Blue Shield Association for the following ancillary services:

• Independent clinical laboratories
• Durable medical equipment suppliers
• Orthotics and prosthetics

The Claims Filing billing guide  has also been updated with the new ancillary claims guidelines.

Defining what Plan is local

For ancillary services that occur on or after Oct. 14, 2012, Wellmark will use the following criteria when processing ancillary services claims.

Please note that these guidelines do not apply to claims submitted for Federal Employee Program (FEP) members. Please continue to follow FEP claims filing guidelines for ancillary services.

Examples of how claims will be processed

Independent Clinical Lab

Your lab processes a specimen that was drawn in Wisconsin for a patient who has Wellmark coverage. Submit the claim to the Wisconsin Plan. If you have an Agreement with the Wisconsin Plan, then the claim will process as a participating provider claim; if not, the claim will process as a non-participating provider claim.

DME Supplier

You ship DME supplies to a patient’s home address in Texas and the patient has Blue Cross and Blue Shield of Michigan coverage. Submit the claim to the Texas Plan. If you have an Agreement with the Texas Plan, then it will process as a participating provider claim; if not, it will process as a non-participating provider claim.

Ancillary providers contracting options

With this change, ancillary providers must submit claims where the service was provided. That Blue Plan may offer you the option of contracting or the claim will be processed as an out-of-network claim.

For example, a member goes to a doctor in Iowa who contracts with Wellmark. The doctor draws a blood sample and sends it to a lab in Missouri. The lab must submit the claim to Wellmark. Unless that lab in Missouri has a contract with Wellmark, the claim will process out-of-network even though the lab may have a contract with the Missouri Blue Plan.

If you are an ancillary provider who currently does business with providers from states other than Iowa or South Dakota, you are encouraged to contact the Blue Plans in those states to discuss contracting/enrollment options.

Wellmark strongly encourages out-of-state independent clinical laboratories and durable medical equipment suppliers to sign both Iowa and South Dakota provider agreements.  Out-of-state providers who sign with Wellmark will be added to the Wellmark provider directories as in-network for both Iowa and South Dakota members. If you are an out-of-state ancillary provider who provides care for Wellmark members who live in Iowa or South Dakota, you will need to contract with Wellmark so that claims process as in-network. Credentialing and enrollment forms are available online.

Use contracted ancillary providers

Contracting Wellmark providers are required to use ancillary providers who also contract with Wellmark so that patients receive the highest level of benefits available.

Please check the provider directory to ensure the laboratories, durable medical equipment suppliers, and orthotic and prosthetic suppliers you are using are in Wellmark’s networks.

Claims submission guidelines

Please include the following data elements on your claims. If this information is not provided on the claim, it may result in claim denials or processing delays.

Independent clinical laboratory

Please complete:

Referring provider

• Field 17B on CMS 1500 Health Insurance Claim Form or
• Loop 2310A (claim level) on the 837 Professional Electronic Submission

If you bill under a supervising physician, please provide the lab the NPI of the supervising physician who is referring the patient, not the NPI of the attending provider seeing the patient.

Durable medical equipment supplier/orthotic & prosthetic supplier

Please complete:

Patient’s address

• Field 5 on CMS 1500 Health Insurance Claim form or
• Loop 2010CA on the 837 Professional Electronic Submission

Referring provider

• Field 17B on CMS 1500 Health Insurance Claim Form or
• Loop 2310A (claim level) on the 837 Professional Electronic format

If you bill under a supervising physician, please provide the lab the NPI of the supervising physician who is referring the patient, not the NPI of the attending provider seeing the patient.

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 CMS 1500 Health Insurance Form or
• Loop 2310C (claim level) on the 837 Professional Electronic Submission

Specialty pharmacy

Hy-Vee Pharmacy Solutions and CVS/Caremark are the two specialty pharmacies contracted to provide specialty pharmacy services to Wellmark members. Their billing practices are unaffected by the ancillary claims filing guidelines.

If you are currently contracted with Wellmark as a Home Infusion Therapy (HIT) provider, you should be aware of some recent changes to credentialing criteria. If you meet the new credentialing requirements for HIT, your billing practices should be unaffected by the ancillary claims filing guidelines.