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!
