Blue Cross and/or Blue Shield Plans (Blue Plans) currently administer Medicaid programs in several states outside of our service area. Because Medicaid is a state-run program, requirements vary for each state and, therefore, each Blue Plan. Medicaid members have limited out-of-state benefits, generally covering only emergent situations. In some cases, such as continuity of care, children attending college out-of-state, or a lack of specialists in the member's home state, a Medicaid member may receive care in another state, and generally the care requires pre-authorization.
Blue Plan Medicaid member ID cards do not always indicate that the member has a Medicaid product. The member ID cards do not include the suitcase logo that is shown on BlueCard member ID cards. However, the member ID cards include a disclaimer on the back that provides information on benefit limitations.
Determining eligibility and benefits and pre-authorizing services
Some states require that out-of-state providers enroll in their state's Medicaid program to be reimbursed. Some of these states may accept a provider's Medicaid enrollment in the state where they practice to fulfill this requirement. If you are required to enroll in another state's Medicaid program, you should receive notification upon submitting an eligibility or benefit inquiry. You should enroll in that state's Medicaid program before submitting the claim. View provider enrollment requirements for Blue Plan Medicaid states (PDF).
Submitting claims and receiving reimbursement
If you submit claims without enrolling in Medicaid, your Medicaid claims will be denied and you will receive the following message from Regence regarding the Medicaid provider enrollment requirements: The state where the member is enrolled in Medicaid requires that providers enroll in their Medicaid program before the Plan can pay the provider. To view provider enrollment requirements for the state where the member is enrolled, please visit regence.com.
You will be required to enroll before the Medicaid claim can be processed and before you receive reimbursement.
Submit claims to your local Blue Plan, Regence. When you see a Medicaid member from another state and submit the claim, you must accept the Medicaid fee schedule that applies in the member's home state.
When billing for a Medicaid member, please remember to check the Medicaid website of the state where the member resides for information on other Medicaid billing requirements. View the Medicaid billing data requirements.
If you provide services that are not covered by Medicaid to a Medicaid member, you will not be reimbursed. You may only bill a Medicaid member for services not covered by Medicaid if you have obtained written approval from the member in advance of the services being rendered. Billing out-of-state Medicaid members for the amount between the Medicaid-allowed amount and charges for Medicaid-covered services is prohibited by Federal regulations.