Code claims the same way you code your other Regence claims and submit electronically with other Regence claims.
- Do not send duplicate claims.
- Do include the complete member number and prefix when you submit the claim.
- Please include the newborn's name, if known, when submitting a claim. Including only "baby girl" or "baby boy" can delay claims processing.
- Do not add or delete any characters to or from the member number. Claims with incorrect or missing prefixes and member numbers delay claims processing.
The claim submission process for international Blue Plan claims is the same as domestic Blue Plan claims. You should submit the claim directly to Regence.
Exceptions to BlueCard claims submissions
Submit claims directly to the member's Blue Plan instead of Regence when:
- You contract with the member's Blue Plan.
- The member ID card doesn't include a prefix.
- The claims are excluded from BlueCard (i.e., stand-alone dental).
- You practice in bordering or shared counties.
- The claim is for an air ambulance pickup outside of our service area.
- You submit laboratory or durable medical equipment (DME) claims.
- The member has Federal Employee Program (FEP) coverage (please follow FEP guidelines).
When in doubt, please submit the claim to Regence.
Claims filing tips for providers in bordering and shared counties
If you contract with Blue Plans in more than one state, follow these guidelines for filing claims.
For providers that practice in bordering areas (contiguous counties), the standard rule is to always file the claim to the Blue Plan located in the state where you provided the service.
- If the member is from a bordering Blue Plan with which you have a contract, then file the claim directly to the bordering Blue Plan.
- If you have a Preferred Provider Organization (PPO) contract with one Blue Plan, but a Traditional (Participating) contract with another Blue Plan, file the out-of-area Blue Plan member's claim by product type. For example, if it's a PPO member, file the claim with the Plan that has your PPO contract.
- If you contract with one Plan but not the other, file all out-of-area (BlueCard) claims with your contracted Plan.
- If you see a member from another Blue Plan that serves the same county but with whom you do not have a contract with, you must submit the claim directly to the member's Blue Plan (not the Blue Plan you contract with).
- If you practice in a county with multiple Blue Plans, submit all claims to the Blue Plan you contract with.
Coordination of benefits
Coordination of Benefits (COB) refers to the prevention of double payment for services when a member has coverage from two or more payers. The member's contract language explains which payer has primary responsibility for payment. Please follow the procedures below for submitting COB claims.
Member has coverage with two out-of-area Blue Plans:
- Send the claim to Regence with the primary member number first.
- After you receive the Explanation of Benefits (EOB), send the information with a new bill to Regence for secondary payment. The claim will not automatically crossover.
Another carrier is the primary payer and a Blue Plan is secondary:
- Bill the other carrier first.
- Send the EOB from the other carrier with the claim to Regence for secondary payment. The claim will not automatically crossover.
Note: If you do not include the EOB information with the claim, the claim will need to be investigated. An investigation could delay your payment or result in a post-payment adjustment.
Telemedicine is transmitting and receiving a patient's clinical data via electronic communication for the purposes of analysis and interpretation. Telemedicine includes, but is not limited to, telephonic services, Internet services and radiology.
For example, a distant teleradiology provider must file claims to the Blue Plan in the state in which the teleradiologist is located. The claims are then processed according to the teleradiologist's participating or non-participating status with that Blue Plan.
Providers should only submit claims to Regence for services they rendered to patients within our service area. Teleradiology services provided outside of our service area should be submitted by the teleradiology provider to his or her local Blue Plan.
View our Virtual Care (Administrative #123) reimbursement policy that applies to physicians, other health care professionals, hospitals and other facilities.
Adjustments and appeals
Contact BlueCard Provider Customer Service if a claim adjustment is required. We will work with the member's Blue Plan for adjustments.
- In situations where a Regence provider is at financial risk for the cost of the claim, the Regence Adverse Determination Appeal Process is followed.
- If the member is financially responsible (e.g., the claim is denied for medical necessity by the member's Blue Plan), the member should submit the appeal to his or her Blue Plan. You can request an appeal on behalf of the member (with signed permission) by sending the information to our correspondence address (attention: BlueCard). We will contact the member's Blue Plan on your behalf.
Dental services are excluded from the BlueCard Program. However, there are times when a procedure performed in a dental office qualifies for payment under the patient's medical plan.
Some common medical billing scenarios include:
- Traumatic injuries
- Sleep apnea appliances
- Biopsies of suspicious lesions
- Temporomandibular joint dysfunction (TMD) orthotics
- Extraction of third molars (not a medical benefit for all Blue Plans)
Submit these claims electronically to Regence. Follow the format of any other claim that is submitted for medical benefits.