The BlueCard Program links providers to all Blue Cross and Blue Shield (BCBS) Plans across the country and around the world through an electronic network of claims processing and payment. The BlueCard Program typically applies when a provider contracted with Wellmark is servicing a member of another BCBS Plan. For providers, the BlueCard program is your one-stop shop for claims submissions, inquiries, status updates, and payment for BlueCard members. BlueCard also provides easy access to member eligibility, benefits and pre-service review.
New requirements for some Medicaid claims
Effective March 1, 2016, all claims for out-of-state Blue Plan Medicaid members must include certain data elements (i.e., form locators). Depending on the plan, these could include, national drug code, rendering and billing taxonomy codes, or rendering and billing national provider identifiers. To view the full list of required form locators, please refer to the Claims Filing section of the Wellmark Provider Guide.
In addition, some states will require providers to enroll with their patient’s plan prior to submitting claims. The Additional Resources section includes a list of states that have special provider enrollment requirements for serving their plan’s Medicaid members, as well as a list of the revenue codes and Current Procedural Teminology (CPT®) codes that require NDCs.
For more information, please refer to the Medicaid Questions and Answers document.
Identifying a BlueCard Member
To determine whether the member has coverage outside his/her local BCBS Plan’s service area, look for the suitcase logo on the ID card.
Letters within the suitcase logo indicate the member has Preferred Provider Organization (PPO) or Exclusive Provider Organization (EPO) coverage for medical services received within or outside the United States. It also means the provider will be reimbursed for covered services in accordance with the provider’s PPO contract with the local BCBS Plan.
A blank (empty) suitcase logo indicates the member has a traditional product such as Health Maintenance Organization (HMO) or Point of Service (POS) products. Out-of-network benefits may or be available; check the member benefits prior to providing services.
If there is no suitcase on the ID card, the member does not have BlueCard coverage. Please note, BCBS Plan ID cards for Medicaid members do not include the suitcase logo, but they do include a disclaimer on the back of the ID card providing information on benefit limitations. For members with such ID cards, you should obtain eligibility and benefit information and prior authorization for services using the same tools as you would for other BCBS members.
Eligibility and Benefits
If you are a Wellmark participating provider, the easiest way to check eligibility and benefit information is through the Out-of-area Membership Search tool .
If you are an out-of-state provider and participate with another BCBS Plan, you can access eligibility and benefits information through your local BCBS Plan’s website. When conducting your search, make sure to include the first three alpha characters on the Wellmark member’s ID card. You can also call 800-676-BLUE (2583).
BlueCard Claim Process
Have a BlueCard claim? Here’s what to expect.
- Member with an out-of-state BCBS Plan receives services from a Wellmark provider.
- The provider submits the claim to Wellmark.
- Wellmark recognizes the BlueCard member, and transmits the claim to the member’s BCBS Plan.
- The member’s BCBS Plan adjudicates the claim according to member’s benefit Plan.
- The member’s BCBS Plan issues an Explanation of Benefits (EOB) to the member.
- The member’s BCBS Plan transmits claim payment information to the provider’s local BCBS Plan.
- Wellmark reimburses participating providers and issues the Provider Claims Remittance (PCR).
A contiguous county is a bordering county to another BCBS Plan’s service area. Claims filing rules for contiguous area providers are based on the permitted terms of the contiguous area contract:
- Provider’s physical location
- Provider’s contract status with the two contiguous states
- The member’s Home Plan
- Location where the member received services
Some common claims filing scenarios that pertain to contiguous counties are:
- If you contract only with the state where you are located, file the claim to your local BCBS Plan.
- If you contract with another state and Iowa as a contiguous county for specific products, submit to the BCBS Plan where you are contracted for the member's particular product.
- If you contract with another state and Iowa, and services are rendered for a patient with BCBS of a state other than the contracted states, submit to the plan in the state where the services are provided.
- If you contract only with Iowa as a contiguous county for specific products, file the claim to Iowa for those specific products. File claims for all other members and products to your local plan.
Tips for BlueCard Claim Submissions
To ensure smooth processing and payment of your claims, please remember to:
- Keep up-to-date patient information and ID card copies.
- Verify BlueCard member benefits, check applicable medical policies and initiate pre-service review using the Medical Policy and Pre-Service Review for Out-of-area Members Web page.
- File the claim to the provider’s local BCBS Plan.
- Obtain claim status and submit claim inquiries through your local BCBS Plan. Wellmark providers can check claim status using the Check a Claim tool.
Claims for independent clinical laboratory services, durable medical equipment, and specialty pharmacy services should be filed to the local BCBS Plan, as described for ancillary services in accordance with the Ancillary Claims Filing instructions
BlueCard Worldwide is a network of more than 9,000 hospitals and 21,000 health care professionals and outpatient care centers around the world. This is provided to members who are traveling or living outside the United States, Puerto Rico, and the U.S. Virgin Islands. Claims support, referrals to providers, translation services and medical motoring is provided to members 24 hours a day, 365 days a year.
- BlueCard Worldwide International Claim Forms
In addition to the information above, you may find the following resources helpful.