# BCBS of AL



## KLS87 (Apr 3, 2011)

I work for a large Orthopaedic practice where we bill for many providers including assistant surgeons.  We are having a difficult time getting payment for assistant surgeons (AS modifier) for BCBS of AL.  I know with our local Anthem they have a grid showing what CPT codes are payable as an assist and which are not. Since our practice is not located in AL, we can not view the secure information on BCBS of AL's website.  I was wondering if anyone was able to get to the secure information on the website and would be able to tell me if they have any information on what CPT codes they show as being necessary for AS. Any help would be great! Thank you!


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## btadlock1 (Apr 4, 2011)

Maybe between one of these links, you'll find your answer. 
I've found that I get further with BCBS and Medicare through Yahoo than through their internal search engines...

https://www.bcbsal.org/providers/manuals/providerManual/guidelinesForAssitantSurgeonClaims.cfm

https://www.bcbsal.org/providers/policies/final/111.pdf

https://www.bcbsal.org/providers/manuals/providerManual/modifiers.cfm

https://bcbsal.org/providers/newPaymentMethodology/modifiers.pdf (The certificate has expired, so your webpage might warn you - just continue on to it...)


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## KLS87 (Apr 6, 2011)

Thank you for the reply Brandi. However, we have used these documents in some of our appeals and BCBS of AL still denies as assistant surgeon not allowed.  If we could get a copy of what codes are allowed as assistant surgeons and which are not...life would be SO much easier. However, we are talking about BCBS and that is not likely to happen.  Thank you again for your help!


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## btadlock1 (Apr 6, 2011)

kblack40 said:


> Thank you for the reply Brandi. However, we have used these documents in some of our appeals and BCBS of AL still denies as assistant surgeon not allowed.  If we could get a copy of what codes are allowed as assistant surgeons and which are not...life would be SO much easier. However, we are talking about BCBS and that is not likely to happen.  Thank you again for your help!



I take it you're not _in_ Alabama?
Are you contracted with your local BCBS? (If not, then this lengthy explanation won't do you much good, but maybe it'll help somebody!) If so, you should refer to your provider manuals for instructions on when you can bill as AS. 

What kind of plan is it? (POS, EPO, PPO, FEP?) And is it secondary to Medicare? (Sorry to give you the 3rd degree, but I do have a reason for asking!)
You may already know this, but BCBS has a bunch of mini-companies (the 'homeplans'), and within each of those, they have the different types of policies, depending on the groups. Nationally-based employers (like Wal-Mart, for example) contract with BCBS in whatever location their company headquarters is located, and the employees carry a plan from that BCBS, regardless of where they actually live. (So every Wal-Mart policy has their homeplan in Arkansas, even if they don't live there.) Most plans participate in "Bluecard" but some don't - it's important to know if your patient's group is one that does).
When providers submit claims, they do it one of 3 ways: 
1. Submit them to their local BCBS
2. Submit them to Medicare, if Medicare is primary. (Medicare will then forward the claim to the patient's homeplan for processing.)
Or, *rarely* - 
3. Submit them directly to the patient's homeplan - this only happens when the patients' plan doesn't participate with Bluecard, and you would have received specific instructions to file claims directly to that plan, either on the back of the card, or by a customer service rep. (These are usually individual policies.)

You may not be contracted with BCBS/AL, but if you're contracted with your local plan and the patient's group participates in Bluecard, the claim is still treated as 'in-network'. (You'd be considered an Out-of-State provider.)

Here's where it gets hairy:
Coverage criteria varies from plan to plan (obviously), so out-of-state claims that deny may have denied based on protocol from the homeplan. These _usually_ pertain to individual benefits, though - sticking with my previous example, some Wal-Mart policies only cover a handful of labs with a routine exam. My local coverage determination may say that it's acceptable to bill a direct LDL measurement with a routine visit, but it's only applicable to plans in my area, so I'd have to follow Arkansas' coverage criteria, because the benefits were assigned from there. (Other plan-based denials include pre-existing conditions, patient eligibility, and coordination of benefits)

Then, there are claims that deny for protocol relating to non-benefit issues, such as timely filing, or issues like yours. These pertain to the provider side of the claims process, not the plan side. If you're contracted with BCBS locally, and the patient's plan is a Bluecard plan, then you would refer to your local BCBS for policies and protocol for billing as an assistant surgeon, regardless of where the plan is based. (You wouldn't receive provider manuals for every plan - just the one you have a contract with.)

The claims process for Bluecard works like this: You submit a claim to your local plan. They review the claim to make sure that it's clean, and to scrub it for coding errors. and then they route the claim to the homeplan. They check it against the patient's benefits and say either 'Yes these services are covered' or 'This plan doesn't have a benefit for this'. They also determine whether the charges should pay or apply to deductible. Once they've made their decision, they send it back to your local BCBS, who checks the claim against your contract and fee schedule. If everything checks out, your local plan issues the payment. This is the reason that you have to call your local BCBS to check claim status, but you call the homeplan to check benefits.

If your patient's group participates in Bluecard, and you fail to send the claim to your local BCBS, you will probably see the claim process OON, when it should be in-network, since your contract provisions won't be recognized. If this is the case, I recommend submitting the claim to your local plan as an appeal (with the BCBS/AL EOB attached - they'll need it.), if your contract or provider manuals indicate that you are allowed to bill for the service. (If you're not sure, or can't find the info, call your BCBS provider relations rep and ask them.) If you don't send it as an appeal, the homeplan will deny it as a duplicate claim when they get it from your plan, and it could take twice as long to fix the problem. You will have to send another claim - your local BCBS will not be able to get it from the other plan.

If they don't participate in Bluecard, you should call your provider relations rep to see if there's anything they can do to help you out. As I mentioned before, you're not privvy to every rule out there, but if you're a participating provider and they're taking a network discount, you should only be subject to the rules you knew existed before seeing the patient, and agreed to follow as a BCBS-contracted provider. 

If your doctor isn't contracted w/BCBS at all, then you are outta luck.  You can try to file a complaint with your state's department of insurance about the claim processing the way that it did, when BCBS/AL didn't provide disclosure on their payment policies to non-par providers, but you probably won't get far unless the plan is fully funded. 

Sorry that was so long - hopefully it will be helpful to somebody!


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## KLS87 (Apr 7, 2011)

Brandi:

We are contracted with our local BCBS and send appeals through our local with the local information stating the denied CPT codes are allowed assists,per local. However, BCBS of AL upholds the denial stating they are not allowed. This is where for us it gets difficult. We have sent several letters to BCBS of AL asking for the summary plan descriptions for these patients so that we can see where in their plan it states this is not allowed. They have yet to provide this to us.  


Unfortunately, I am not in Alabama and because I am not in Alabama I can not research the secure side of their website.  When I research the secure side of my local Anthem's website, I can see what codes are allowed as assists, which codes are not, which codes can be billed bilaterally and so forth.  If I could find this document for Alabama, it would be so very grateful. This is why I was hoping I could find someone on the AAPC forum from AL that could assist with this. I have tried contacting them directly and tried getting information from Anthem rep. This was my last resort.  I appreciate all of insight.


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## btadlock1 (Apr 7, 2011)

kblack40 said:


> Brandi:
> 
> We are contracted with our local BCBS and send appeals through our local with the local information stating the denied CPT codes are allowed assists,per local. However, BCBS of AL upholds the denial stating they are not allowed. This is where for us it gets difficult. We have sent several letters to BCBS of AL asking for the summary plan descriptions for these patients so that we can see where in their plan it states this is not allowed. They have yet to provide this to us.
> 
> ...



I feel your pain. It's unbelievably frustrating to deal with BCBS in these kinds of situations. Have you contacted your provider relations rep (not provider customer service - the people that take care of your credentialing issues) - they can usually help with this kind of stuff, and at the very least, maybe act as a liason to AL for you and get you the info you need. They can't just arbitrarilly deny your claim and then refuse to tell you what policy they followed to do it - by law, you're entitled to full disclosure in writing. 

I had a very similar situation recently with GHI in NY - they denied some X-Rays for one of our internists, who owns the equipment and interpreted the results, as not being payable to the provider type. We're not contracted with them and TX is pretty far from NY, so we would have never known that they have a special arrangement with radiologists in their area to only allow a select list of radiology charges to be payable to non-radiologists (they called it a 'privileging list', and I had to talk to 5 different people before I found somebody who knew what codes were even on the list.) I appealed several times, telling them that we had no way of knowing about a payment policy that was only issued to participating providers halfway across the country, and since our provider was acting within her scope of practice, we had no reason to believe that she would be ineligible to bill the service. I filed a complaint with our insurance dept., but they couldn't really do anything, since it was a self-funded plan outside of their jurisdiction. I hope you have better luck than I did! Have a good day!


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## colorectal surgeon (Apr 7, 2011)

http://www.facs.org/ahp/pubs/2007physasstsurg.pdf

you may find the above document helpful in appealing the denials. This covers all CPT codes and indicates nationally how often assistants are used in each procedure


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## WBittinger (Mar 20, 2019)

*Assistant Surgeons*

Hi Kaylee,
I found this information for Assistant Surgeons on BCBS of AL website. I have attached the webpage hopefully that will help 


https://providers.bcbsal.org/portal...e1977-e7c0-4092-9ed7-e77c2ecd5b23?version=1.3


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