How routing works for Blue Cross Blue Shield (BCBS) claims and eligibility checks

Blue Cross Blue Shield (BCBS) isn't one company. It's a collection of 30+ independent regional payers, each licensed to use the Blue Cross and Blue Shield names in their area.

BCBS payers participate in the national BlueCard program. With BlueCard, a patient can see providers who are contracted with any participating BCBS payer. The patient's care is still covered by their "home" plan, the plan they have insurance through.

For example, a patient covered by BCBS of Alabama sees a provider in Texas. The provider is contracted with BCBS of Texas, not BCBS of Alabama. Because both payers participate in BlueCard, BCBS of Alabama still covers the patient's care.

BlueCard usually makes billing easier, but it can create confusion for providers. Billers don't always know which BCBS payer to bill or where eligibility data is coming from.

This guide explains how BlueCard routes eligibility checks and claims. It also shows how to read Stedi's BCBS eligibility responses and avoid payer rejections.

What is BlueCard and how does it work?

BlueCard lets providers treat patients covered by other BCBS payers. The provider runs eligibility checks and submits claims through the provider's local plan – the local BCBS payer the provider is contracted with. The local plan forwards the provider's eligibility checks and claims to the patient's home plan through BlueCard, then returns the home plan's responses.

For example, a provider who's contracted with BCBS of Illinois can see a patient covered by BCBS of Michigan. The provider runs eligibility checks and submits any claims for the patient to BCBS of Illinois. BCBS of Illinois forwards the transactions to BCBS of Michigan through the BlueCard network. BCBS of Michigan sends its responses back through BCBS of Illinois, which returns them to the provider.

BlueCard terms

BCBS payers use the following terms to describe each payer's role in BlueCard.

Term	What it is
Home plan	The BCBS payer that covers the patient.
Local plan	The BCBS payer the provider has a contract with, usually in the provider's area. Also called the host plan.

Is a patient's home plan always in the state or area they live in?

The home plan isn't always in the patient's state. For example, for an employer-sponsored group plan, the home plan is the BCBS payer that issued the employer's plan.

That payer can be in a different state from where the patient lives. Patients can look up their home plan using the BCBS member services lookup.

Does each BCBS payer cover a single state?

Not always. Many BCBS payers, like BCBS of Illinois, cover one state, but some don't. For example, Wellmark is a BCBS payer that covers both Iowa and South Dakota. California has two BCBS payers: Anthem Blue Cross and Blue Shield of California.

What's a BCBS alpha prefix?

The first 3 characters of a BCBS member ID. The prefix identifies the patient's home plan, which is how BlueCard knows where to route eligibility checks and claims.

Each BCBS payer uses many prefixes, but each prefix belongs to one payer. For example, AZ Blue uses more than 100 prefixes, such as FZI, XBC, and M2K.

Should a provider run eligibility checks with the local plan or home plan?

The provider's local plan. Any BlueCard-participating BCBS payer can forward a check to the patient's home plan.

What happens if a provider runs an eligibility check with the home plan?

It depends on the patient's home plan. Some home plans return a normal response. Others reject checks from providers outside their network. If the home plan rejects the eligibility check, rerun it with the local plan.

Should a provider submit claims to the local plan or home plan?

In most cases, the provider should submit claims to the provider's local plan. The local plan forwards the claim to the patient's home plan through BlueCard. The home plan processes the claim and decides what to pay.

For example, an Illinois provider sees a patient covered by BCBS of Michigan. Stedi's eligibility response lists BCBS of Michigan as the home plan. The provider still submits the claim to BCBS of Illinois, the local plan that the provider is contracted with.

When does a provider need to submit claims to the home plan?

The rules vary by BCBS payer. Some BCBS payers require or allow the provider to submit claims to the patient's home plan if:

The provider is contracted with the home plan.
The provider is in a county or area next to the home plan's service area.

What's the local plan if a provider is contracted with more than one BCBS payer?

The local plan is the BCBS payer for the area where the provider is located. For example, an Illinois provider is also contracted with Anthem BCBS of Indiana. The provider can submit claims for Anthem BCBS of Indiana patients to Anthem BCBS of Indiana. Claims for all other BCBS patients still go to BCBS of Illinois, the provider's local plan.

Some areas have more than one local plan. In California, Anthem Blue Cross and Blue Shield of California both cover the state. A provider contracted with both can usually submit to either.

What happens if a provider submits a claim to the wrong BCBS payer?

The payer may reject the claim. For example, if a provider submits a claim to the patient's home plan instead of the provider's local plan, the home plan may reject it. To fix the rejection, submit the claim to the local plan.

How can a provider get the home plan's payer ID?

Stedi's enriched eligibility responses include the home plan for most BCBS patients. To get the patient's home plan in the response, include the following in the eligibility request:

Patient's first name
Patient's last name
Patient's date of birth
Patient's full member ID, including the 3-character alpha prefix

Stedi adds the home plan's name and payer ID to the eligibility response. You can use these when the provider needs to submit claims to the home plan. You don't need to set anything up.

Examples
If you're using our API or SDKs, Stedi returns eligibility data in one of two response shapes, depending on the endpoint you call.

Responses from our Real-Time Eligibility Check JSON endpoint organize benefits in a plans array. Responses from our Batch Eligibility Check, Insurance Discovery, Real-Time Eligibility Check Raw X12, and Legacy Real-Time Eligibility Check JSON endpoints use a benefitsInformation array.

The following examples show both, labeled plans and benefitsInformation.

The home plan is in the plans[].benefits.statuses[].relatedEntities array with a type of PARTY_PERFORMING_VERIFICATION:

"plans": [
  {
    "benefits": {
      "statuses": [
        {
          "status": "ACTIVE_COVERAGE",
          "relatedEntities": [
            {
              "type": "PARTY_PERFORMING_VERIFICATION", // Home plan
              "name": { "organization": "Blue Cross Blue Shield of Alabama" },
              "payerId": "00510BC"
            }
          ]
        }
      ]
    }
  }
]

The home plan is in the benefitsInformation[].benefitsRelatedEntities array with an entityIdentifier of Party Performing Verification:

"benefitsInformation": [
  {
    "code": "1",
    "serviceTypeCodes": ["30"],
    "benefitsRelatedEntities": [
      {
        "entityIdentifier": "Party Performing Verification", // Home plan
        "entityType": "Non-Person Entity",
        "entityName": "Blue Cross Blue Shield of Alabama",
        "entityIdentification": "PI",
        "entityIdentificationValue": "00510BC"
      }
    ]
  }
]

Are there cases where Stedi doesn't return a home plan in eligibility responses?

Yes. There are cases in which Stedi doesn't add the patient's home plan to the eligibility response, such as when the patient is in a Federal Employee Program (FEP) plan. For the full list of exceptions, see BCBS home plan in the docs.

How can a provider tell if a patient is on an FEP plan?

FEP covers U.S. federal employees, retirees, and their families. To tell if a patient is on an FEP plan, check their member ID. FEP member IDs typically start with an R.

Should a provider submit claims for FEP patients to the home plan or local plan?

The local FEP plan, the BCBS payer that handles FEP claims where services were rendered. FEP plans aren't part of BlueCard.

In some states, professional and institutional FEP claims go to different BCBS payers. For example, in California, Anthem Blue Cross handles institutional FEP claims, and Blue Shield of California handles professional FEP claims.

If a claim for an FEP patient goes to the wrong BCBS payer, that payer may reject it with a 277CA claim acknowledgment containing:

A claim status category code of A3 (Returned as unprocessable claim)
A claim status code of 21 (Missing or invalid information)

The payer's message may tell you to file the claim with the "Home Plan." Here, "Home Plan" means the local FEP plan that handles professional claims. To fix the rejection, resubmit the claim to that local FEP plan.

Examples

In 277CA Report API responses, the status is in the claimStatus.informationClaimStatuses array. statusMessage contains the payer's message:

"claimStatus": {
  "informationClaimStatuses": [
    {
      "informationStatuses": [
        {
          "healthCareClaimStatusCategoryCode": "A3", // Returned as unprocessable claim
          "statusCode": "21" // Missing or invalid information
        }
      ],
      "statusMessage": "Professional FEP claims must be filed directly to the Home Plan."
    }
  ]
}

In X12 claim acknowledgments, the status is in the STC segment of Loop 2200D (Claim Status Tracking Number). STC12 contains the payer's message:

TRN*2*PCN123~ // patient control number
STC*A3:21*20261005*U*150********Professional FEP claims must be filed directly to the Home Plan.~ // status codes and payer message

Which BCBS payer should a provider send claim status checks to?

The provider's local plan. A claim status check asks the payer where a claim is in processing. The local plan has the record of the claim. It forwards the check to the patient's home plan through BlueCard.

If the local plan can't find the claim, try running a claim status check with the home plan. For details, see BCBS / BlueCard routing in the docs.

Exception: FEP plans
Send claim status checks for FEP claims to the BCBS payer the provider submitted the claim to.

Which BCBS payer returns claim acknowledgments and ERAs?

The provider's local plan. However, an Electronic Remittance Advice (ERA) may list the payer ID for the patient's home plan instead of the local plan's payer ID. The provider doesn't need to complete ERA transaction enrollment with the home plan to receive these ERAs.

Exception: FEP plans
For FEP claims, the ERA comes from the BCBS payer the provider submitted the claim to, not through BlueCard.

Get started with Stedi

To get started with Stedi, sign up for a free sandbox account. It takes less than two minutes. No credit card is required.

When you're ready, upgrade to production on our pay-as-you-go plan. There are no monthly minimums or setup fees. You only pay for the transactions you use.

Twitter LinkedIn