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Learn about BlueCard®

Roles and Responsibilities

What are Capital Blue Cross’ responsibilities?

Capital Blue Cross’ responsibilities include all provider-related functions, such as:

  • Being the single contact for all claims payments, customer service issues, provider education, adjustments, and appeals.
  • Pricing claims and applying pricing and reimbursement rules consistent with provider contract agreements.
  • Forwarding clean claims to the member’s Blue plan for adjudication.
  • Conducting appropriate provider reviews and/or audits.
  • Confirming that providers are performing services and filing claims appropriately.
  • Conducting HIPAA standard transactions.
  • Training providers on BlueCard.

What are the home plan’s responsibilities?

  • Adjudicating claims.
  • Responding to prior authorization and pre-certification requests/inquiries.
  • Requesting medical records through Capital Blue Cross when review for medical necessity, determination of a pre-existing condition, or high cost/utilization is required.

What are the provider’s responsibilities?

  • Obtaining benefits and eligibility information, including covered services, copayments, and deductible requirements.
  • Filing claims with the correct local plan and include the required elements to ensure timely and correct processing, such as:
    • Current member ID card number
    • All other party liability information
    • All member payments
  • Submitting requested medical records in a timely manner

Eligibility and Benefits

How can you get member eligibility information?

You can get member eligibility information by submitting a Blue Exchange Eligibility & Benefits Inquiry (HIPAA transaction 270) request through Capital Blue Cross, or by calling 800.676.2583. If prior authorization or precertification information is required, please call 800.676.2583.

  • Please use the appropriate Service Type codes for the service provided. Use of the general Service Type “30” (Health Benefit Plan Coverage) or Service Type “1” (Medical Care) may not provide enough information to address all related benefits, limitations, or place of service requirements.
  • Verify the member’s cost share amount before processing the payment. Copay, coinsurance, deductibles, and accumulated benefits are available on the electronic Blue Exchange Eligibility & Benefits Response (HIPAA transaction 271) to the HIPAA transaction 270. Please do not process the full payment upfront.

What specific information should you obtain?

1) Request the most current ID card at every visit, since new ID cards maybe be issued to members throughout the year. Member ID cards may include one of several logos identifying the type of coverage and provider reimbursement level.

  • Blank (empty) suitcase o Traditional, HMO (Health Maintenance Organization), POS (Point of Service), or Limited Benefit Product benefits.
  • PPO in suitcase o PPO (Preferred Provider Organization) or EPO (exclusive provider organization) benefits
  • No suitcase o Medicaid, State Children’s Health Insurance Programs (SCHIP) administered as a part of a state’s Medicaid program, or Medicare Complementary and Supplemental products (Medigap) benefits.

2) Request specific information when contacting the home plan for benefit and eligibility information:

  • Eligibility
  • Benefits
  • Cost-sharing
  • Prior authorization/pre-certification requirements
  • Care/utilization management requirements
  • Concurrent review requirements

Claim Submission

How should you bill claims for out-of-area members?

Bill these claims the same way you bill claims for Capital Blue Cross members. When submitting the claim:
  • The member ID numbers should be reported exactly as shown on the ID card. Do not add, omit, or alter any characters from the member ID number.
  • Indicate on the claim any payment you collected from the patient.
  • Only submit medical records if requested.

What should you do if you haven’t received a response to your initial claim submission?

If you have a question regarding the status of an outstanding claim, you can submit an electronic Blue Exchange Claim Status Request (HIPAA transaction 276) or contact Capital Blue Cross. Do not send in a duplicate claim. Sending another claim or resubmitting a claim slows down the claims payment process and creates confusion for the member.

Coordination of Benefits

How should you handle Coordination of Benefits (COB) when a member has Blue-on-Blue coverage, or has another carrier?

In cases where a member has Blue-on-Blue coverage (has dual coverage with the same and/or differing Blue plans):

  • When submitting claims, enter the correct Blue plan name as the secondary carrier. This may be different from Capital Blue Cross. Check the member’s ID card for additional verification or ask them to complete the Universal Blue COB Questionnaire available in the Capital Blue Cross Provider Library.
  • On the electronic HIPAA transaction 837 or paper claim, check box 11D “Yes” or “N” for professional claims, or complete fields 50, 58-62 for institutional claims.
    • For professional claims, indicate if the member does not have other insurance. Leaving the box unmarked can cause the member’s home plan to stop the claim for investigation.
  • Review the EOP/EOB from the primary Blue plan prior to submitting a claim to the secondary Blue plan to avoid duplicate submissions. The primary Blue plan may have forwarded the claim to the secondary Blue plan through BlueCard. If the secondary claim was not handled by Capital Blue Cross, forward a copy of the claim to Capital Blue Cross with any Other Party Liability (OPL) information.
  • Carefully review the payment information from all payers involved on the remittance before billing the patient for any potential liability.
  • In cases where there is more than one payer and another Blue plan or commercial insurance carrier is the primary payer, submit the other carrier’s name and address or EOB with the claim to Capital Blue Cross. You may also download the Universal Blue COB Questionnaire (available on the Capital Blue Cross Provider Library) that the member can complete and sign at the time of service. Please ensure that the form is completely filled out and at a minimum, include your name and tax identification or NPI number, the policy holder’s name, group number and identification number including the threecharacter prefix and the member’s signature. Then send it to Capital Blue Cross with the claim.
  • If a non-Blue plan is primary and a Blue plan is secondary, submit the claim to Capital Blue Cross only after receiving payment from the primary payer. Include the EOP.

Prior Authorization/Pre-Certification

Are you required to cooperate with the member’s Blue plan prior authorization/pre-certification programs?

While out-of-area BlueCard members are responsible for obtaining prior authorization or pre-certification from their Blue plan, most providers choose to handle this obligation on the member’s behalf, with the exception of inpatient facility services. Members may be held financially responsible if necessary approvals are not obtained and the claim is denied. You may have to manage debt collection in this situation.

When verifying member eligibility and benefits, request information on prior authorization and pre-certification, care management/utilization management, and concurrent review as required for inpatient or outpatient services.

How can you obtain prior authorization/pre-certification information for out-of-area members?

Member prior authorization or pre-certification information can be obtained both electronically and telephonically.

  • General information on prior authorization and pre-certification can be found on the provider portal under Medical Policy and Precert/Preauth for Out-of-Area Members. Use the three character prefix found on the member ID card.
  • Use the Electronic Provider Access (EPA) to gain access to an out-of-area member’s home plan provider portal. This will allow you to have the same access to electronic pre-authorization capabilities as the Home plan’s local providers. When utilizing the EPA, you will be routed to the Home plan’s EPA landing page where you will be able to connect to the available electronic pre-service review processes.
  • You can also call 800.676.2583 to obtain prior authorization or pre-certification information. When prior authorization or pre-certification for a specific member is handled separately from eligibility verification, your call will be routed directly to the area that handles prior authorization or pre-certification. You will choose from four options depending on the type of service for which you are calling:
    • Medical/Surgical
    • Behavioral Health
    • Diagnostic Imaging/Radiology
    • Durable/Home Medical Equipment (D/HME)
  • If you call 800.676.2583 for eligibility and prior authorization or pre-certification, your eligibility inquiry will be addressed first.
  • If a prior authorization and pre-certification determination is not provided at the time of the call, the determination may be communicated to a different area (i.e. utilization management).
  • With the submission of an Eligibility HIPAA transaction 270 request through Capital Blue Cross, the Eligibility HIPAA transaction 271 response may indicate that a prior authorization or pre-certification is required.

Are facilities that are paid primarily on a Diagnosis-related Group (DRG)/case basis required to obtain approvals for length-of-stay beyond the original approval?

When possible, home plans will consider Capital Blue Cross’ payment arrangement with the facility, and if appropriate, adjust UM protocols accordingly. Many DRG contracts have stop loss provisions and revert to an alternative payment method (i.e. percent of charges) at a particular point during the course of stay. Home plans may work closely with the facility and/or Capital Blue Cross to manage these potentially high-cost cases.

  • Claims may be subjected to length-of-stay review and sanctions. Even if you are contacted as a DRG facility, a concurrent review may occur.
  • The home plan cannot split payment for claims with Capital Blue Cross DRG pricing. The home plan must either approve or deny the entire claim.
  • If the treatment plan changes during the inpatient stay, new certification will be needed. You can call 800.626.2583 and request to speak with the Utilization Review area or submit a Blue Exchange Referral/Authorization Inquiry (HIPAA transaction 278) to Capital Blue Cross.
  • You can inquire about concurrent review processes when verifying eligibility and benefits or when obtaining pre-certification. Benefits of the concurrent review process are:
    • Assists with coordinated discharge planning
    • Identifies care management opportunities
    • Reduces readmission

Why do Blue plans sometimes indicate that a service/procedure is authorized or certified, but then determine it’s non-covered/denied when the service is adjudicated?

This may happen when there is a benefit limitation restricting: who may render the service, where they are rendered, how they are billed, or the presence of a benefit maximum. Additional factors include pre-existing conditions, additional services not included in the initial plan of treatment, and revised length of stays that do not match the prior authorization or pre-certification.

You are encouraged to communicate with Blue plans immediately any changes in treatment or setting to ensure authorization is not interrupted. Prior authorization and pre-certification do not guarantee payment.

Are you required to hold the patient harmless for penalties assessed for not following the Blue plan authorization protocols?

The out-of-area BlueCard member is responsible for obtaining pre-certification or prior authorization from his/her Blue plan. He or she is responsible for any penalty assessed for non-compliance. The only exception is inpatient facility services, which are your responsibility.

Medical Records

Should you include medical records with the original claim?

You should not submit medical records or other clinical information unless requested. You will be notified if medical records or other information is needed.

  • If you receive requests for medical records from the home plan, please submit them as requested.
  • Follow the submission instructions given on the request, using the specified address, email, or fax number. Contact information for for medical records may be different than the address you use to submit claims.
  • There is a difference between reviewing a claim for medical necessity after the service has already been rendered and reviewing a prior authorization for medical appropriateness:
    • Medical necessity - validates the service is medically necessary according to the member’s medical policy.
    • Medical appropriateness - validates that services rendered match the prior authorization and dollar amounts.
  • When a claim has been denied for medical records and the records have been submitted to Capital Blue Cross, we recommend waiting a minimum of 20 business days before submitting a follow-up request for status.
  • If you are the rendering or performing provider for a service, include the name and address of the referring or ordering provider on your original claim submission.

Medical, Benefit, Payment Policy

Which plan’s medical policy applies for out-of-area members?

Only a member’s Blue plan medical policy applies to BlueCard claims.

Should a member’s Blue plan ever directly contact an out-of-area provider?

The member’s Blue plan should only contact an out-of-area provider to solicit, clarify, or confirm clinical information for case management or disease management activities.

How should you bill mother/newborn claims for out-of-area members?

Bill them the same way you bill claims for Capital Blue Cross members.

Who determines the use of revenue/procedure codes?

It is Capital Blue Cross’ responsibility. When a claim contains non-standard codes, it maybe be rejected, and you may be asked to resubmit with the standard code.

Who determines the appropriate use of modifiers?

It is Capital Blue Cross’ responsibility.

How much can you bill an out-of-area BlueCard member?

You should only bill for applicable deductibles, copays, co-insurance, non-covered services, and/or medical management penalties specifically indicated as “Patient Responsibility” on the remittance for out-of-area BlueCard members. You may not bill the out-of-area member for the difference between billed charges and the Capital Blue Cross-negotiated allowance.

How does Capital Blue Cross determine whether a charge is the responsibility of the member or the contracting provider?

Provider responsibility is determined by the provider contract. If your contract explicitly states that you will not be reimbursed for a specific service or timeframe, and cannot bill the member, you are liable for the charge.

Member responsibility is determined by the member’s benefit contract. If the contract explicitly states the service is not covered, the member is liable for the charge.

Under what circumstances is there no payment due to you, the provider?

Capital Blue Cross prices claims according to the terms of its provider contracts. If you contract has a clause stating that you are liable for any costs associated with services rendered outside of your scope of practice, Capital Blue Cross will indicate no payment is due to you. If the member’s benefit allows the service, but your contract does not, benefits will be approved, but no payment is due to you and you should write it off.

Claims Payment

How is provider payment determined?

  1. Capital Blue Cross applies pricing and reimbursement rules consistent with your contractual agreements.
  2. The home plan adjudicates the claim based on eligibility and contractual benefits.

Who pays you?

Provider-payable claims will be paid by Capital Blue Cross based on your contract, subject to the member’s plan.

Medicare Crossover

All Blue plans crossover Medicare claims for services covered under Medigap and Medicare Supplemental products. Medicare clams will automatically be submitted to the Blue secondary payer, so your office does not need to submit an additional claim.

How do you submit Medicare primary/Blue plan secondary claims?

Submit claims to your Medicare intermediary and/or Medicare carrier.

  • Enter the correct Blue plan name as the secondary carrier. This may be different from Capital Blue Cross. Check the member’s ID card for additional verification.
  • Include the prefix as part of the member ID number. The member’s ID card will include this prefix.

When will you receive payment for Medicare crossover claims?

The claims you submit to the Medicare intermediary will be crossed over to the Blue plan after processing. This may take up to 14 business days. This means that the Medicare intermediary will be releasing the claim to the Blue Plan for processing about the same time you receive the Medicare remittance advice. As a result, it may take an additional 14-30 business days for you to receive payment from the Blue Plan.

To determine if your claim has crossed over, review the Remittance Advice (RA) you receive from Medicare. The RA will show a crossover indicator that Medicare has submitted the claim to the appropriate Blue plan and the claim is in progress. If there is no crossover indicator on the RA, providers should submit the claim along with the Medicare RA to Capital Blue Cross.

Medicare Advantage

How do you handle Medicare Advantage (MA) claims?

For Medicare Advantage, submit claims to Capital Blue Cross. Do not bill Medicare directly for any services rendered to a Medicare Advantage member.

  1. Medicare Advantage members have distinctive product logos on their medical ID card to help you recognize them. All logos have the term “Medicare Advantage” in the design.
  2. Verify eligibility by contacting 800.6762583 and providing the member ID number prefix. Be sure to ask if Medicare Advantage benefits apply.
  3. Review the remittance notice concerning Medicare Advantage plan payment, member’s payment responsibility, and balance billing limitations.

What does Medicare Advantage PPO Network Sharing mean?

If you are a contracted Medicare Advantage PPO provider with Capital Blue Cross and you see Medicare Advantage PPO members from other Blue plans, they will be extended the same contractual access to care and will be reimbursed in accordance with your Capital Blue Cross-negotiated rate. They will receive in-network benefits in accordance with their member contract.

If you are not a contracted Medicare Advantage PPO provider with Capital Blue Cross and you provide services for any Blue Medicare Advantage member, you will receive the Medicare-allowed amount for covered services. For urgent or emergency care, you will be reimbursed at the member’s in-network benefit level. Other services will be reimbursed at the out-of-network benefit level.

Ancillary Claims Filing

Where should I file ancillary claims?

Ancillary providers include independent clinical laboratories, durable/home medical equipment and supplies, and specialty pharmacies. File claims for these providers as follows:

  • Independent clinical laboratory (Lab)
    • The plan in whose state* the referring provider is located
  • Durable/home medical equipment and supplies (D/HME)
    • The plan in whose state* the equipment was shipped or purchased at a retail store
  • Specialty pharmacy
    • The plan in whose state* the ordering physician is located *If you contract with more than one plan in a state for the same product type (i.e. PPO or traditional), you may file the claim with either plan.

Contiguous Counties/Overlapping Service Areas

What are the rules for filing claims in contiguous counties?

Rules are based on provider contracts, which may include:

  • Provider location (i.e. which plan’s service area your office is located in)
  • Provider contract with the two counties (i.e. are you contracted with one or both service areas?)
  • The member’s home plan and location of his or her home and work (i.e. is the member’s home plan one of the contiguous counties’ plans?)
  • The location where services were received (i.e. does the member work and reside in one contiguous county and see a provider in another contiguous county?)
  • Guidelines do not apply to ancillary claims filing. Ancillary claims must be filed to Capital Blue Cross based on the type of ancillary service provided.

What are the rules for filing claims in overlapping service areas?

This depends on what plan(s) you contract with, the type of contract (e.g. PPO or traditional), and the type of contract the member has with his or her home plan.

  • If you contract with all local Blue plans in your state for the same product type, you may file an out-ofarea member’s claim with either Blue plan.
  • If you have a PPO contract with one Blue plan, but a traditional contract with another Blue plan, file the out-of-area Blue plan member’s claim by product type.
    • For example, if it’s a PPO member, file the claim with the plan that has your PPO contract.
  • If you contract with one plan but not the other, file all out-of-area claims with your contracted plan.

Additional Information

What is an Administrative Services Only (ASO) account?

ASO accounts are self-funded. Capital Blue Cross administers claims on behalf of the account, but does not fully underwrite the claims. ASO accounts may have benefit or claims processing requirements that differ from non-ASO accounts. There may be specific requirements that affect:

  • Medical benefits
  • Submission of medical records
  • Coordination of benefits
  • Timely filing limitations

Capital Blue Cross receives and prices all local claims, handles all interactions with providers (with the exception of utilization management interactions), and makes payment to the local provider. As with any member benefit contract, be sure to verify member eligibility and benefits when rendering service.

How should clearinghouses be notified of changes in claims processing guidelines or policy?

It is your responsibility to ensure any changes to claims processing guidelines or policy is communicated to your billing service, clearinghouse, or payer. Failure to do so in a timely manner may result in delays or denials of payment.

Claim Filing Tips

For Facility Providers


Provider Contracts with Capital Blue Cross (CBC) 
 Provider Contracts with CBC and Highmark
Provider Contracts with CBC and CareFirst BCBS of Maryland
Member is covered by CBC
 Submit claims to CBC. These are local claims, not BlueCard claims
 Submit claims to CBC. These are local claims, not BlueCard claims 
 Submit claims to CBC, for services provided in Maryland. These are local claims, not BlueCard claims
Member is covered by Independence Blue Cross Personal Choice and POS (plan Code 327) or Blue Plan outside of PA excluding West Virginia and Delaware (See Below)
 Submit claims to CBC for services provided in CBC's 21 county service area. For services that were provided at a location outside of CBC's 21 county service area - submit to the Blue Plan that is associated with that location.
Submit the claim to either CBC (only services provided within CBC's 21 county service area) or Highmark for processing subject to the constraint noted below. These are BlueCard claims. Filing Tip: Do NOT send the claim to both CBC and Highmark. Please choose one local Blue Plan to submit the claim.
 Submit claims to CareFirst BCBS of Maryland, for services provided in Maryland . These are BlueCard claims for members of most Blue Plans. They are local claims for member's of CareFirst. 
Member is covered by Highmark, Blue Cross of Northeastern PA, Independence Blue Cross, Highmark Blue Cross Blue Shield of West Virginia or Delaware.
 Submit claims to Highmark. These are local claims, not BlueCard claims. (Plan Codes 070, 274, 275, 362, 378, 363, 364, 455, 441, 941, 443, 943, 444, 944) 
Submit claims to Highmark. These are local claims, not BlueCard claims. (Plan Codes 070, 274, 275, 362, 378, 363, 364, 455, 441, 941, 443, 943, 444, 944)
 If provider also contracts with Highmark, submit claims for services provided in Maryland to Highmark. These are local claims not BlueCard claims. If provider does not contract with Highmark, submit claims for services provided in Maryland to CareFirst BCBS of Maryland. These are BlueCard claims.  
Note: Providers with only a PPO contract with one Local Blue Plan and only a Traditional contract with another Local Blue Plan are to submit claims for services provided to out-of-state Blue Plan Members based on the Member's coverage. For example, if a Provider has only a Traditional program contract with Highmark and has a PPO contract with Capital Blue Cross, the Provider should submit claims for out-of-state Members with PPO coverage to Capital Blue Cross. In addition, please keep in mind that Members enrolled in Blue HMOs are covered under the Traditional contract, and claims should be submitted to a Blue Plan which has a Traditional contract. 

*BlueCard Eligibility 1-800-676-BLUE (2583)
*BlueCard Provider Customer Service number for claim issues: 1-877-892-6298
 Products included in the BlueCard Program:
  • Traditional
  • Comprehensive
  • PPO
  • POS
  • Medigap
  • HMO

For Professional Providers


Professional Provider Contracts with Capital Blue Cross (CBC) 
 Professional Provider Contracts with CBC and Highmark
Professional Provider Contracts with CBC and CareFirst BCBS of Maryland
Member is covered by CBC
 Submit claims to CBC. These are local claims, not BlueCard claims
 Submit claims to CBC. These are local claims, not BlueCard claims 
 Submit claims to CBC, for services provided in Maryland. These are local claims, not BlueCard claims
Member is covered by Independence Blue Cross Personal Choice and POS (plan Code 327) or Blue Plan outside of PA excluding West Virginia and Delaware (See Below)
 Submit claims to CBC for services provided in CBC's 21 county service area. For services that were provided at a location outside of CBC's 21 county service area - submit to the Blue Plan that is associated with that location.
Submit the claim to either CBC (only services provided within CBC's 21 county service area) or Highmark for processing subject to the constraint noted below. These are BlueCard claims. Filing Tip: Do NOT send the claim to both CBC and Highmark. Please choose one local Blue Plan to submit the claim.
 Submit claims to CareFirst BCBS of Maryland, for services provided in Maryland . These are BlueCard claims for members of most Blue Plans. They are local claims for member's of CareFirst. 
Member is covered by Highmark, Blue Cross of Northeastern PA, Independence Blue Cross, Highmark Blue Cross Blue Shield of West Virginia or Delaware.
 Submit claims to Highmark. These are local claims, not BlueCard claims. (Plan Codes 070, 274, 275, 362, 378, 363, 364, 455, 441, 941, 443, 943, 444, 944) 
Submit claims to Highmark. These are local claims, not BlueCard claims. (Plan Codes 070, 274, 275, 362, 378, 363, 364, 455, 441, 941, 443, 943, 444, 944)
 If provider also contracts with Highmark, submit claims for services provided in Maryland to Highmark. These are local claims not BlueCard claims. If provider does not contract with Highmark, submit claims for services provided in Maryland to CareFirst BCBS of Maryland. These are BlueCard claims.  
Note: Providers with only a PPO contract with one Local Blue Plan and only a Traditional contract with another Local Blue Plan are to submit claims for services provided to out-of-state Blue Plan Members based on the Member's coverage. For example, if a Provider has only a Traditional program contract with Highmark and has a PPO contract with Capital Blue Cross, the Provider should submit claims for out-of-state Members with PPO coverage to Capital Blue Cross. In addition, please keep in mind that Members enrolled in Blue HMOs are covered under the Traditional contract, and claims should be submitted to a Blue Plan which has a Traditional contract. 

*BlueCard Eligibility 1-800-676-BLUE (2583)
*BlueCard Provider Customer Service number for claim issues: 1-877-892-6298
 Products included in the BlueCard Program:
  • Traditional
  • Comprehensive
  • PPO
  • POS
  • Medigap
  • HMO

Specialty Pharmacy, Independent Labs and Durable Medical Equipment Providers

Provider Type
 How to File (Required Fields of Information)
Where to File
 Pennsylvania Filing Guidelines 
Independent Clinical Laboratory (any type of non hospital based laboratory) 
 Referring Provider: Field 17 on CMS 1500 Health Insurance Claim Form or Loop 2310A (claim level) on the 837 Professional Electronic Submission.
File the claim to the Plan in whose state the specimen was drawn - Where the specimen was drawn will be determined by which state the referring provider is located. Example: Blood is drawn in lab located in Maryland. Blood analysis is done in Pennsylvania. File claim to Maryland.
 If the referring physician is located within the CBC 21 county service area AND the Member is covered by Highmark Blue Cross and Blue Shield, Independence Blue Cross, Blue Cross of Northeastern PA, Highmark Blue Cross Blue Shield Delaware or West Virginia - submit claims to Highmark (Plan Codes 070, 071, 274, 275, 362, 377, 378, 363, 364, 865, 455, 441, 570, 941, 443, 943, 444, 944). If the referring physician is located within the CBC 21 county service area for all other Blue Plan members and CBC members should be submitted to Capital Blue Cross.
Durable/Home Medical Equipment/Supplies
 Patient's Address: Field 5 on CMS 1500 Health Insurance Claim Form or Loop 2010CA on the 837 Professional Electronic submission.
Ordering Provider: Field 17 on CMS 1500 Health Insurance Claim Form or Loop 2420E (line level) on the 837 Professional Electronic Submission.
Place of Service: field 24B on the CMS 1500 Health Insurance Claim Form or Loop 2300, CLM05-1 on the 837 Professional Electronic submissions.
Service Facility Location Information: Field 32 on CMS 1500 Health Insurance Claim Form or Loop 2310A (claim level) on the 837 Professional Electronic Submission. 
 File the claim to the Plan in whose state the equipment was shipped to or purchased in a retail store. Example: A) Wheelchair is purchased at a retail store in the Capital Blue Cross service area. File claim to Capital Blue Cross. B) Wheelchair is purchased on the internet from an online retail supplier in Maryland and shipped to the Capital Blue Cross service area. File claim to Capital Blue Cross.
 If the equipment was shipped to or purchased in a retail store within the CBC 21 county service area AND the Member is covered by Highmark Blue Cross and Blue Shield, Independence Blue Cross, Blue Cross of Northeastern PA, Highmark Blue Cross Blue Shield Delaware or West Virginia - submit claims to Highmark (Plan Codes 070, 071, 274, 275, 362, 377, 378, 363, 364, 865, 455, 441, 570, 941, 443, 943, 444, 944). Equipment shipped to or purchased in a retail store within the CBC 21 county service area for all other Blue Plan members and CBC members should be submitted to Capital Blue Cross.
Specialty Pharmacy (Types of Service: Non-routine, biological therapeutics ordered by a healthcare professional as a covered medical benefit as defined by the member’s Plan’s Specialty Pharmacy formulary.) 
Referring Provider: Field 17 on CMS 1500 Health Insurance Claim Form or Loop 2310A (claim level) on the 837 Professional Electronic Submission.
File the claim to the Plan whose state the Ordering Physician is located. Example: Patient is seen by a physician in Maryland who orders a specialty pharmacy injectable for this patient. Patient will receive the injections in the Capital Blue Cross service area where the member lives for 6 months of the year. File claim to Maryland. 
 If the ordering physician is located within the CBC 21 county service area AND the Member is covered by Highmark Blue Cross and Blue Shield, Independence Blue Cross, Blue Cross of Northeastern PA, Highmark Blue Cross Blue Shield Delaware or West Virginia - submit claims to Highmark (Plan Codes 070, 071, 274, 275, 362, 377, 378, 363, 364, 865, 455, 441, 570, 941, 443, 943, 444, 944). If the ordering physician is located within the CBC 21 county service area for all other Blue Plan members and CBC members - submit claims to Capital Blue Cross. 
Note: Providers with only a PPO contract with one Local Blue Plan and only a Traditional contract with another Local Blue Plan are to submit claims for services provided to out-of-state Blue Plan Members based on the Member's coverage. For example, if a Provider has only a Traditional program contract with Highmark and has a PPO contract with Capital Blue Cross, the Provider should submit claims for out-of-state Members with PPO coverage to Capital Blue Cross. In addition, please keep in mind that Members enrolled in Blue HMOs are covered under the Traditional contract, and claims should be submitted to a Blue Plan which has a Traditional contract. 

*BlueCard Eligibility 1-800-676-BLUE (2583)
*BlueCard Provider Customer Service number for claim issues: 1-877-892-6298
 Products included in the BlueCard Program:
  • Traditional
  • Comprehensive
  • PPO
  • POS
  • Medigap
  • HMO

Common Resources