Reminder: Filing Contiguous County Claims for Highmark Members and Non-Highmark Members

Highmark contracts with providers located in counties that are part of another Blue Plan’s service areas but border Highmark service areas. These Highmark contiguous county provider contracts apply only to Highmark members who work or reside in the Highmark service area.

If a provider — located in a county contiguous to a Highmark plan service area — contracts with that Highmark plan (“Contiguous County Contracting Highmark Plan”) and renders services to any Highmark plan member who works or resides in any Highmark plan service area, the provider must file the claim to the Contiguous County Contracting Highmark Plan. See below the response to the question, “How Contiguous Claims Filing Rules Apply for Highmark Service Areas”.

If the Highmark member does not work or reside in the Highmark service area, the provider must file the claim for the Highmark member to the local Blue Plan where the provider is located and regular BlueCard claim filing rules apply.

Claims filing rules for contiguous area providers are based on the following:

  • Provider’s physical location (the Blue Plan service area where the provider’s office is located).
  • Provider’s contract status with the two Blue Plans (Is the provider contracted with only one or both service areas?).
  • Member’s Home Plan and where the member works and resides.
  • Location where the member received services.

Criteria for Submitting to the Member’s Home Plan

Contiguous county claims filing rules allow claims to be filed directly to the member’s Home Plan when each of the following criteria are met:

  • The Home Plan’s member lives or works in the Home Plan’s service area, and
  • The Home Plan contracts with a provider located in its contiguous county, and
  • Service is provided in the provider’s office located in a contiguous county.

If each of the criteria is not met, the claim must be filed to the Blue Plan in whose service area the provider is located.

IMPORTANT: The contiguous county claims filing rules don’t apply to ancillary claims filings (independent labs, durable/home medical equipment and supplies, and specialty pharmacy) or in overlapping service areas, where multiple Blue Plans share the same service area.

For claim submission guidelines for ancillary claims and overlapping service areas, please see the “Overlapping Service Areas” and “Ancillary Claims Filing Rules” sections in the Highmark Provider Manual’s Chapter 2.6: The BlueCard Program.

How Contiguous Claims Filing Rules Apply for Highmark Service Areas

Blue Cross Blue Shield Association contiguous county claims filing rules consider all Plans operating in multiple service areas as one service area. Therefore, Highmark plans in all of our service areas in Delaware, New York, Pennsylvania, and West Virginia are viewed as one service area for claims filing.

What You Can Do to Avoid Claim Denials

To help avoid unnecessary claim denials, it is recommended that contracted contiguous county providers have a process in place to assure you request and document a Highmark member’s home and work addresses accurately. If it is determined that the member does not live or work in the Highmark service area where you have a contiguous county contract, it should be documented that claims are to be filed to your local Blue Plan as BlueCard claims.

Dually Contracted

Providers in contiguous counties to Highmark Plan areas should be dually contracted so that they can bill claims for non-Highmark members to the appropriate Plan. By participating with BOTH plans, providers can facilitate appropriate claims submission for Highmark members and non-Highmark members.


 

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