Blue Cross Blue Shield
State-SpecificFederation of 34 independent, locally operated Blue Cross Blue Shield companies providing coverage in every U.S. state and territory. State-specific pages coming soon.
Important: Payer policies change frequently. Always verify current requirements using official payer manuals, provider portals, and direct contact with the payer. DenialPro provides educational guidance and references but does not replace official payer policy. The information on this page is for educational purposes only and may not reflect the most current payer requirements.
Overview
Blue Cross Blue Shield is a federation of 34 independent, locally operated companies that collectively provide health insurance coverage in every U.S. state and territory. Each BCBS company operates independently with its own provider network, policies, and claim adjudication systems. The Blue Card program allows members of one BCBS plan to receive services in other BCBS service areas while the home plan processes the claim. The Federal Employee Program (FEP) is a separate nationally-administered BCBS plan.
Official Resources
Timely Filing Limits
Timely filing varies by BCBS company — typically 90 to 365 days from date of service. FEP (Federal Employee Program) allows 365 days. Check the specific BCBS plan's provider manual for the exact deadline.
Appeal Time Limits
Appeal deadlines vary by plan and state — typically 90 to 180 days from the denial date. Check the specific EOB or denial letter for the appeal deadline and instructions. FEP has specific appeal timelines that may differ from local BCBS plans.
Corrected Claim Process
Submit corrected claims using Frequency Code 7 on the CMS-1500 or 837 transaction for most BCBS plans. Some BCBS plans require specific correction forms or a corrected claim submission through the provider portal. Check the specific plan requirements.
Prior Authorization
Prior authorization requirements vary by BCBS company and plan. Common services requiring prior auth: advanced imaging (MRI/CT/PET), specialty drugs, durable medical equipment, behavioral health services, and certain surgical procedures. Use the BCBS provider portal to check requirements.
Referral Requirements
HMO plans typically require referrals; PPO plans generally do not. Check the member's specific plan type. BCBS HMO plans require PCP referrals before specialist visits.
Eligibility Verification
Verify eligibility through the local BCBS provider portal, the national BCBS provider portal (for Blue Card members), or the 270/271 transaction. Check for deductible, copay, coinsurance, and plan type. For Blue Card members, the home plan's eligibility information is available through the host plan's portal.
Claim Status Resources
Check claim status through the local BCBS provider portal or the national portal for Blue Card claims. Most BCBS plans also support the 277 claim status transaction.
Coordination of Benefits
Determine coordination of benefits using the birthday rule for dependents and the active employee rule for adults. BCBS plans follow standard COB rules. Report all other coverage on the claim.
Modifier Policies
BCBS companies follow NCCI modifier policies with plan-specific variations. Check the local BCBS provider manual for specific modifier requirements. The 25 and 59 modifiers are commonly scrutinized.
Telehealth Policies
Telehealth coverage varies by BCBS company and plan. Many BCBS plans expanded telehealth coverage after COVID-19. Check the specific BCBS plan's telehealth policy for covered services, modifiers (typically 95 or GT), and originating site requirements.
Medical Necessity Resources
Medical necessity criteria are set by each BCBS company, often using InterQual or MCG (Milliman Care Guidelines) criteria. Check the specific BCBS plan's medical policy database for covered services and criteria.
NDC Billing Requirements
NDC requirements vary by BCBS company. Many BCBS plans require NDCs for physician-administered drugs. Check the specific BCBS plan's provider manual for formatting and submission requirements.
Common Denial Reasons
- CO-16 (missing/incomplete information)
- CO-50 (not medically necessary)
- CO-97 (bundling)
- CO-45 (charges exceed fee schedule)
- CO-197 (authorization/notification absent)
- CO-25 (duplicate claim/service).
Common Rejection Reasons
- Missing referral (HMO plans)
- missing prior authorization
- invalid member ID format
- eligibility not active on date of service
- missing NPI
- invalid taxonomy code.
Documentation Requirements
Documentation must support the level of service billed, medical necessity, and the treatment provided. BCBS plans may request medical records for review. Check the specific BCBS provider manual for documentation requirements.
Electronic Claim Submission
Submit claims electronically via the 837 transaction to the specific BCBS plan. The BCBS plan processes claims based on the member's ID prefix (the first 3 characters of the member ID). Use Availity or the BCBS provider portal for direct submission.
Provider Portal
Each BCBS company maintains its own provider portal. Availity is a common multi-payer portal used by many BCBS companies. The national BCBS provider portal supports Blue Card claim status and eligibility.
Provider Manual
Each BCBS company publishes its own provider manual. Check the specific BCBS company's provider website. FEP has a separate provider manual available on the FEP website.
Contact Information
Contact the specific BCBS company's provider relations department. Contact information is typically on the back of the member's ID card and on the BCBS company's provider website.
Educational Notes
BCBS is a federation — always identify the specific BCBS company by the member ID prefix (first 3 characters). Blue Card claims are submitted to the local (host) BCBS company but adjudicated by the home plan. FEP claims follow a different process. Check the member's ID card for plan type and contact information.
Always Verify
Payer policies change frequently. This profile is for educational purposes only. Always verify current requirements using the official payer portal, provider manual, and direct communication with the payer.
Explore Other Payers
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