Wiki Out-of- Network Provider

[Sbrooks225]

I am new to working insurance denials. If a current date of service in 2015 is denied for Out-Of-Network and the claim is not being sent to the local plan first but being billed directly to the insurance company on the patient's card my questing is - Can the claim be resubmitted to the local plan for reprocessing when the facility is in-network with the PPO network in the local plan? There has been some serious debate in the billing office regarding billing the home plan first when services are being performed out of the plan's network.

 

[austin408]

Billing Local/HomePlan

I see this mostly with BCBS and we typically bill our local unless otherwise specified. This however does not guarantee we will get paid. There are few plans that do not allow their patients to be seen outside of their homeplan network, so even if you are seeing a PPO member from another homeplan and you are participating with your local, there is no guarantee that your services will be covered (some employers and some exchange plans may have this stipulation).

Here is how I would check to find out where to submit claims and if the services will be covered:

1. During benefit verification with the home plan, ask where claims should be submitted for an out-of-area or out-of-state provider. The home plan will typically ask if you are participating with your local PPO when you verify coverage/eligibility, explain that you are and ask if the patient's benefits will cover your services as in-network.
2. Check your contract to see if it outlines the claims submission procedure for this type of situation.
3. Talk to your provider representative to find out what the claims submission procedure is for this situation.

As I said earlier, we see this a lot with BCBS, we bill our local and they transmit our claim to the home plan. We get paid by our local and have to contact the local's BlueCard department in order to discuss any claims, as the home plan will not discuss claims with us, only benefits. Many times when you verify benefits with the representative at the home plan they will be able to tell you where to submit a claim. If it is a BCBS claim you are discussing, I would think your claims should probably be submitted to your local, but it is always best to get confirmation from the plan, contract, or provider representative first.

Hope this information is helpful!