- April 29, 2020
- Posted by: CB&C
- Category: Publications
What does ‘Blue Card’ mean anyway? What is the difference between Horizon BC/BS and those out of state BC/BS plans?
Good questions. So let’s first compare ‘The Blues’ to other carriers you are familiar with. Let’s use UHC. They are a nationwide insurance carrier. Therefore, wherever you are in the US, there is a really good chance you will be able to find a participating provider if you need healthcare.
Ok—so how does that compare to BC/BS? Well, I am sure you have noticed that Horizon BC/BS is only 1 of many BC/BS carriers in the country. If a carrier wants the right to use the BC/BS name and emblem, they have to apply to do so through the Blue Card Association. They are then assigned an area that they can function as a carrier under the BC/BS umbrella.
Each BC/BS carrier is a separate and distinct company—and there are quite a few of them. It is obviously NOT feasible for providers to directly contract with every BC/BS carrier in the country. So in comparison to the UHC example—how does a Horizon BC/BS insured member find an in-network provider if they need healthcare services in another state? Hence—the Blue
Card Program. This program basically allows insured members of—for example BC/BS of Florida – to seek out participating providers of the local BC/BS carrier to utilize their in-network benefits. The out of state BC/BS is usually referred to as the ‘home plan’ and our BC/BS carrier (Horizon BC/BS) is usually referred to as the ‘local plan’. This concept makes sense right?
If you think about that scenario, it makes sense that as a provider in NJ, you have to submit the claims to the Blue Card address in Neptune for Out of State BC/BS patients. How else is that BC/BS (again let’s use Florida BC/BS) carrier going to know if you are a participating provider with your local BC/BS carrier or not if the claim does not pass through them first? Since they are separate and distinct carriers, BC/BS of Florida has no information available regarding provider contracts with Horizon BC/BS. Therefore, the only way for the program to work is that the provider submits the claims to the local carrier Horizon BC/BS, and they identify you as a participating or non participating provider before forwarding the claim to the home plan for processing.
Furthermore if you are a participating provider with Horizon BC/BS, they will re-price the claim at the Horizon BC/BS fee schedule and apply their payment guidelines before forwarding it to the home plan. If you are a non-participating provider, the claim is supposed to be forwarded from Horizon BC/BS to the home plan identifying you as a non-par provider. In that case the claim is generally paid at the processing guidelines of that home plan. Please note that doing follow-up on these patients is tricky. The home plan holds the benefits, not Horizon BC/BS, yet when you call the home plan directly, they will instruct you to call the local.
When you call Horizon BC/BS Blue Card with a problem, they will send ‘an inquiry’ to the home plan to try to get the claim fixed. This often does not work. If you feel you are getting the run-around, you need to be assertive and get a supervisor. You should also learn how to decide what can be handled through Horizon BC/BS Blue card and what you really do need to be persistent and call the home plan directly for a resolution.
