FAQs - Billing, Benefits & Processing Issues

Can providers do up front collection of member responsibility amounts?

The BCBSKS Policies and Procedures for institutional providers allow for up front collection of member responsibility amounts including coinsurance, deductible, non-covered and shared payment amounts.

1. Up front collection of these amounts is the provider's decision. BCBSKS does not have a policy that requires providers to collect up front.
2. If the member has already satisfied part of their deductible, coinsurance or share payment, providers can only bill up front for the balance.
3. Member responsibility must be calculated based on the BCBSKS MAP or allowance and not on the total charge.
4. If the up front collection results in an overpayment that is due the patient, a refund must be made to them timely.

Refer to the BCBSKS Policies and Procedures for exact contract language.

When Medicare is the primary payer, sometimes after they process, the balances don’t automatically crossover for payment under the members BCBS contract. Is there anything the provider can do to fix this?

If the patient is enrolled in BCBSKS:

1. Contact the BCBSKS customer service center and ask them to verify the information that's loaded on the eligibility file that we send to Medicare. Be prepared to furnish customer service with:
   1. Medicare health insurance (HI) number,
   2. Medicare effective dates (Part A & B)
2. Send (fax) to BCBSKS a copy of the third screen of the provider CWF file from the Medicare FISS system. This screen shows the Medicare health insurance number as well as the Part A & B effective dates. Be sure to include the BCBSKS ID number when you send it to us.

If the patient is enrolled in an out-of-area BCBS plan you can contact our BlueCard customer service center and they will contact the member's home plan to determine why claims are not crossing over from Medicare. You should also be prepared to furnish customer service with the Medicare HI number and effective dates.

For BCBSKS members, contact our customer service center at:

Topeka Local (785) 291-4182
Toll Free 1-800-648-1756
FAX (785) 290-0711

For out-of-care BCBS plan members, contact our BlueCard customer service center at:

Topeka Local (785) 291-4058
Toll Free 1-800-432-3990 ext. 4058

Our hospital hosts a health fair each year. Will BCBSKS pay for services provided at the health fair?

Coverage for any service, including those provided at a health fair, is determined by the member's contract with BCBSKS. If the member has benefits for a service they receive at a health fair, the provider is required to submit a claim and payment would be allowed. See the examples below.

If you offer services at a health fair (or any type of promotion) at a discounted rate, BCBSKS expects to be billed that discounted rate for all services provided to it's members during that same time frame. This requirement can be found in the BCBSKS Policies and Procedures for most contracting hospital types and reads as follows:

"If the Contracting Provider, through a short-term promotion such as a health fair, offers services for a reduced price, BCBSKS must also be billed the lower rate during that time frame."
SCENARIO #1 – health fair is offering lab services

1. Done on hospital grounds.
2. Done with hospital equipment.
3. Done by hospital personnel.
4. The patient is not registered as an outpatient and there is no direct physician care (no physician orders).

Most BCBSKS member contracts do not cover lab services without a physician order.
SCENARIO #2 – health fair is offering lab services

1. Done off hospital grounds.
2. Specimens are brought back to the hospital and ran on hospital equipment.
3. Hospital personnel volunteers at the health fair but lab personnel is used to run the specimens.
4. The patient is not registered as an outpatient and there is no direct physician care (no physician orders).

Most BCBSKS member contracts do not cover lab services without a physician order.
SCENARIO #3 – health fair is offering screening mammogram services

1. Done off hospital grounds.
2. Done with hospital equipment.
3. Done by hospital personnel.

SCENARIO #4 – health fair if offering screening mammogram services

1. Done on hospital grounds.
2. Done with hospital equipment.
3. Done by hospital personnel.

Most BCBSKS member contracts cover screening mammogram services without a physician order. Therefore, the screening mammogram MUST be billed to BCBSKS.

REMINDER: any time a provider offers services through a health fair (or similar promotion) at a discounted rate, BCBSKS must be billed the lower rate for all services provided to BCBSKS members during the same time frame.

Does BCBSKS Cover Medical Nutritional Therapy (MNT) and Diabetic Education?

The locally developed and marketed Blue Cross and Blue Shield of Kansas (BCBSKS) member contracts do not include a benefit for medical nutritional therapy.

These contracts (often referred to as traditional BCBSKS contracts) typically include a benefit for diabetic education which may, and quite likely, includes nutritional guidance. Diabetic education services meeting the guidelines as outlined in the BCBSKS Institutional Provider Manual, Chapter 8; Benefits and Exclusions are billed to BCBSKS with HCPCS G0108 or G0109.  The BCBSKS claims processing system looks for the presence of a diabetes diagnosis code in the primary diagnosis code field on the claim.  If not in the primary field, benefits would not be allowed.

Medical nutritional therapy CPT/HCPCS 97802, 97803, 97804, G0270 or G0271 (or any other assigned code) is not covered for members enrolled in traditional BCBSKS contracts.

When provided by hospital staff, these services are billed using the UB-04 billing format.

NOTE: Some administrative services only (ASO) or national groups may provide benefits for MNT.

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