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What are BlueCross and/or BlueShield Medicare Advantage claims?

Medicare + Choice and Medicare Risk claims are now known as "Medicare Advantage." The Centers for Medicare and Medicaid Services (CMS) have authorized several Blues Plans to offer these products as a replacement for their current Medicare product. Plans are also being allowed to develop preferred provider organization (PPO) and health maintenance organization (HMO) networks for these products as well as accessing the current Medicare agreements. The Blue Plan is the primary payer for Medicare Advantage claims.

How do I identify a member with a Medicare Advantage Policy?

Members who enroll in a Medicare Advantage product agree to get most services through network providers, but may seek service in another state. Ask for the member’s ID card. Members will not have a standard Medicare card, but they will have a BlueCross and/or BlueShield logo on their ID cards.

Verify eligibility by contacting 800-676-BLUE (2583) and providing the prefix. Be sure to ask if Medicare Advantage benefits apply. If you have trouble getting eligibility information, please record the prefix and report it to your provider advocate.

Where do I submit out-of-state Medicare Advantage claims?

Submit claims to your local Blue Plan. Do not bill Medicare directly for any services rendered to a Medicare Advantage member. Payment is made directly by a Blue Plan.

I accept Medicare assignment. Will I be paid my PPO contractual allowable amount?

Based upon CMS regulations, if you are a provider who accepts Medicare assignment and renders service to Medicare Advantage members from other Blue Plans, you will be reimbursed the equivalent of the current Medicare allowable amount for all covered services. This amount may be less than your charge amount or different from your PPO contractual allowable amount. CMS regulations state that the Medicare allowable amount is considered payment in full.

Can I balance bill the patient?

You can collect only the applicable cost sharing (i.e., copayment) amounts from the member at the time of service and may not otherwise charge or balance bill the member. Other than the applicable member cost sharing amounts, reimbursement is made directly by the Blue Plan.

How can I find out the status of a patient's claim?

You can make claim status inquiries electronically to BlueCross BlueShield of South Carolina through My Insurance ManagerSM.

Why is the Remittance Advice for a Medicare Advantage claim important?

Please review the remittance to see references to CMS requirements for Medicare-allowable amounts, member’s payment responsibility and balance billing limitations.

If you are a provider who accepts Medicare assignment and treats members from other Blue Plans, please note the following:

Medicare Advantage Claims

Medicare-Related Claims

What are BlueCross and/or BlueShield Medicare-related (Medicare primary) claims?

These are claims for members whose primary insurance coverage is Medicare. A BlueCross and BlueShield Plan offers them secondary/supplemental coverage.

Examples include:

  • Medigap (also called Medicare supplemental, Medicare complementary and Medicare extended)
  • Medicare carve-out

How do I identify a member with a Medicare-related policy?

Check the logos on the members' ID cards. Members often carry more than one ID card. When Medicare is the primary payer, the ID card will be a standard Medicare card with no BlueCross or BlueShield logos. Members may also have a separate ID card with the Blue brands for Medicare secondary coverage.

Where do I submit BlueCross and/or BlueShield Medicare-related claims?

When Medicare is primary, please submit claims to your Medicare intermediary. If the member has secondary coverage, it is essential that you enter the correct Blue Plan name as the secondary carrier. Do not enter BlueCross BlueShield of South Carolina if the secondary coverage is with another Blue Plan. Verify the Blue Plan name by contacting 800-676-BLUE (2583).

After receiving the explanation of payment, or Medicare Remittance Notice (MRN), from Medicare, review the indicators:

  • If the indicator on the remittance shows that the claim was crossed over, Medicare has forwarded the claim on your behalf to the appropriate Blue Plan and the claim is in process. You can make claim status inquiries electronically to BlueCross BlueShield of South Carolina through My Insurance Manager.
  • If there is no crossover indicator on the remittance, submit the claim electronically to BlueCross BlueShield of South Carolina with the primary payment information. For electronic claim status inquiries, use My Insurance Manager.
  • Please be sure to use the member’s ID card number to include the prefix when submitting or inquiring about these claims. Without the prefix, we cannot route the claim correctly to the plan responsible for payment.

Why is the remittance advice for a Medicare-related claim important?

Do not submit Medicare-related claims to your local Blue Plan before receiving an MRN from the Medicare intermediary. Duplicate claims submissions are inefficient and can delay claim processing.

Who do I contact for questions?

If you have any questions, please contact your provider advocate.

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