Are you a Horizon BCBS non–participating provider?
Our physical therapy and modality CPT codes (the ‘97’ codes) and exams provided to your patients? Do you have patients insured by BCBS carriers other than Horizon BCBS (eg – Empire BCBS, Highmark BCBS, Anthem BCBS, etc.)? If you answered yes to these questions, we encourage you to closely evaluate these patient’s EOBs for processing errors.
Most of you are aware of the Horizon BCBS policy regarding the non-payment of the ‘97’ codes and exams.
However, chiropractors often don’t realize that this policy is NOT common to all BCBS carriers. As a matter of fact, many other BCBS carriers including those listed above DO cover exams and ’97’ CPT codes when rendered by a Chiropractor (dependent on that carrier’s guidelines and the insured’s policy). That said however, these services are often denied when billed for these patients by Chiropractors in New Jersey. Why?
To understand what is happening you first need to understand the claim submission process for all BCBS patients. Horizon BCBS is the BCBS carrier for New Jersey (the ‘local plan’). There are many other BCBS carriers servicing states across the country (the ‘home plans’). Participating AND non-participating providers are required to submit claims for all BCBS patients to the ‘local plan’. This process allows Horizon BCBS to advise the ‘home plan’ on whether the provider is participating or not. In this fashion, Horizon BCBS is able to dictate how the claim should be paid for participating providers (applying Horizon BCBS fees & contract guidelines). If a provider attempts to bypass Horizon BCBS and submit the claim directly to a ‘home plan’, the claim is usually denied or returned stating ‘claim must be submitted to the local carrier’.
This requirement (for this purpose) seems reasonable relative to Horizon BCBS participating providers as they have signed a contract to accept Horizon BCBS chiropractic policies and fee schedule. It only becomes unreasonable when Horizon BCBS also dictates how non-participating providers should be paid. Remember non-participating providers have NO signed contract binding them to accept Horizon BCBS policies and fee schedule. Shouldn’t it then be simple that reimbursement for BCBS patients insured by other carriers be determined by the policy that the patient holds and the guidelines of that specific carrier?
In contacting BCBS carriers to question when such services are denied, the problem appears to be in the manner in which Horizon BCBS is forwarding the claims to the ’home plans’. Therefore the resolution to this problem seems simple enough. When Horizon BCBS receives a claim for a member insured by a BCBS carrier (other than Horizon) from a non-participating provider, the claim should be forward on simply indicating: This is not a Horizon BCBS participating provider. We are unable to dictate how the claim should be processed. Please process per the carrier’s policies and guidelines.
In closing, this issue can be summed up by simply saying – If there is no signed contract between non-participating providers & Horizon BCBS the only function BCBS should have in claim processing is to indicate such and pass the claim through to the ‘home plan’.
For more information regarding this issue, please contact us at the info below:
