Blue Cross Blue Shield Changes Filing Issues

In November of 2010, the Blue Cross Blue Shield Association (BCBSA) made a ruling change that states any ancillary provider, such as an independent lab, must file with Blue Cross Blue Shield (BCBS) in the state in which the specimen was collected.

Prior to this, the claim would be filed with the local BCBS and they would forward the claim to the appropriate state. Now BCBS in Florida is no longer accepting out of state claims. Moreover, Florida states it will not contract with out of state independent labs. This trend will continue as more states follow suit.

The other, and more malevolent change, deems providers must send specimens to labs in the same state the specimen was collected unless the required testing is not available in that state. BCBS states that the change is not recent, but ‘clarification’ has recently been issued to help determine the origination of the specimen and identify the correct local plan.

We are seeing claims denied as ‘out of network’ by BCBS of Florida (BlueOptions). They state the providers in Florida were notified not to use out of state labs.

Speaking with a BCBS Network Manager NOT in the state of Florida revealed that pathology and specialty labs should be exempt from this rule, and that Florida’s denials could be related to a Place of Service 81 designation which is for independent labs. Place of Service tells the carrier the origination of the specimen, such as office, independent lab, ambulatory center, etc.

Although we currently are experiencing this issue only with Florida, BCBS does say this was a national directive. Regardless of whether this is a new ruling or simply a new clarification of a standing ruling, it has the potential to be a large problem. This may affect your business if you have out of state specimens coming into your lab.

We are currently in the process of speaking with the National Association and getting a definitive answer.