Frequently asked questions

General questions

  • Claims issues/adjustment requests
  • Policy questions
  • Product/benefit information
  • Payment issues
  • Provider demographics/practice information

(401) 274-4848
1-800-230-9050
Monday through Friday, 8:00 a.m. to 4:30 p.m.

Monday through Friday, 8:00 a.m. to 4:30 p.m.

Having key pieces of information available for our representatives will allow us to help you more efficiently. Please have the following pieces of information available:

  • Your NPI number
  • Patient information, including name and member identification number
  • Claim information, including date of service, procedure code, charge, and claim number
  • Settlement number, if applicable
  • Settlement date, if applicable

Claims should be submitted to:

Blue Cross & Blue Shield of Rhode Island
ATTN: Claims Department
500 Exchange Street
Providence, Rhode Island 02903-2699

Exceptions

In the following instances, claims should not be submitted to BCBSRI:

  • When there is another medical insurance carrier that is primary over BCBSRI. These claims should be filed to the primary carrier.
  • When the claims are workers' compensation claims that are not through Beacon Insurance Company (Beacon claims are filed with BCBSRI). These claims should be filed to the appropriate workers' compensation carrier.

Prior authorization for the high-end imaging services (including CT scans, PET scans, MRI, MRa, and cardiac imaging) can be obtained by contacting our radiology management vendor, eviCore. eviCore accepts authorizations requests by phone, fax, and online.

  • Get immediate approval by submitting your request at www.evicore.com.
  • Call 1-888-233-8158 from 8:00 a.m. to 9:00 p.m., Eastern, Monday through Friday.
  • Download a form from the Forms & Resources section of the Evicore website and fax it to 1-888-693-3210.

eviCore is a trademark of eviCore healthcare, LLC, an independent company that provides utilization review for select healthcare services on behalf of BCBSRI.

Prior authorization for aftercare and acute care coordination services can be obtained by calling our Utilization Management Department at (401) 272-5670. If you are calling from out-of-state, please call one of our toll free numbers: 1-800-635-2477 or 1-800-727-2300. Authorizations for these services can also be obtained by submitting a Preauthorization Request on our secure Provider portal.

Information to have available for our representatives:

  • Patient name
  • Identification number
  • What the procedure is
  • Date of the procedure
  • Location (hospital or other)

Please complete a Practitioner Change form and a W-9 form. If you prefer to speak with a representative, call the Physician and Provider Service Center:

(401) 274-4848
1-800-230-9050
Monday through Friday, 8:00 a.m. to 4:30 p.m.

The primary care provider (PCP) coordinates the patient's care by referring the patient to specialists when needed. All BCBSRI PCPs are required to use our web-based referral management tool to generate referrals. Please click here to see our list of products that require a referral.

When reading your settlement, use the reimbursement column to calculate payments. If you have any questions regarding your settlement, call the Physician and Provider Service Center:

(401) 274-4848
1-800-230-9050
Monday through Friday, 8:00 a.m. to 4:30 p.m.

We recommend preauthorization for all inpatient procedures. We also review services that could be considered cosmetic. Please Contact Physician and Provider Service Center: 

(401) 274-4848 
1-800-230-9050 
Monday through Friday, 8:00 a.m. to 4:30 p.m.

Call the Physician and Provider Service Center:

(401) 274-4848
1-800-230-9050
Monday through Friday, 8:00 a.m. to 4:30 p.m.

BlueLine is an automated system that is available 24 hours a day, 7 days a week. BlueLine provides quick and easy access to membership, eligibility, and benefit information, as well as detailed claims status.

To access BlueLine:

  1. Call (401) 272-1590 or 1-800-327-6712
  2. Follow the instructions for entering your provider number
  3. Press one (1) for benefits or two (2) for claims
  4. Enter the member's identification number
  5. Press 0 at any time to reach a representative

BlueCard

BlueCard is a national program that enables members of one Blue Cross and/or Blue Shield plan (Blue plan) to obtain healthcare services while traveling or living in another Blue plan's service area. The program links participating healthcare providers with the independent Blue plans across the country and in more than 200 countries and territories worldwide through a single electronic network for claims processing and reimbursement.

The program allows you to conveniently submit claims for patients from other Blue plans, domestic and international, to your local Blue plan — BCBSRI.

BCBSRI is your contact for claims payment, problem resolution, and adjustments.

A national program that offers members traveling or living outside of their Blue plan's area the preferred provider organization (PPO) level of benefits when they obtain services from a physician or hospital designated as a BlueCard PPO provider. To find out if you're a BlueCard PPO provider, visit www.bcbs.com.

Similar to BlueCard traditional and BlueCard PPO, BlueCard Managed Care/POS (point-of-service) program is for members who reside outside their Blue plan's service area. However, unlike other BlueCard programs, BlueCard Managed Care/POS members are enrolled in HMO networks and primary care provider (PCP) panels. Therefore, you should treat these members as you treat any other BCBSRI Managed Care/POS member, applying the same referral practices and network protocols.

The BlueCard program applies to all inpatient, outpatient, and professional claims. This includes traditional, preferred provider organization (PPO), point-of-service (POS), and health maintenance organization (HMO) products.

Dental services and prescription medication benefits are excluded from the BlueCard program. In addition, claims for Federal Employee Program (FEP) are exempt from the BlueCard program.

When members of Blue plans arrive in your office or facility, be sure to ask for their current member identification (ID) card. The card identifies BlueCard members with an alpha-numeric prefix. The ID cards may also have:

  • A blank suitcase logo
  • A PPO in a suitcase logo
  • No suitcase logo

There are two types of alpha prefixes: plan specific and account specific. Plan specific alpha prefixes are assigned to every Blue plan and start with X, Y, Z, or Q. The first two positions indicate the Blue plan to which the member belongs. The third position identifies the product in which the member is enrolled.

  • First character X, Y, Z or Q
  • Second character A-Z
  • Third character A-Z

Account specific prefixes are assigned to centrally processed national accounts. National accounts are employer groups that have offices or branches in more than one area, but offer uniform benefits coverage to all of their employees. Account specific alpha prefixes:

  • Start with letters other than X, Y, Z, or Q
  • Typically relate to the name of the group
  • Use all three positions to identify the national account

The three-character* alpha-numeric prefix is the key element used to identify members and route out-of-area claims. The prefix identifies the Blue plan or national account to which the member belongs. It is critical for confirming a patient's membership and coverage. The remaining portion of the member's ID consists of seven to 14 alpha and/or numeric characters. We suggest you make copies of the front and back of the member's ID card and share this information with your billing staff.

It's important that you do not add or delete any alpha/numeric characters in the member's ID number.

*You may see member ID cards with a four-character alpha-numeric prefix (e.g., members of HMSA Blue Cross Blue Shield of Hawaii).

To determine the member's participation status, check the suitcase logo.

  • A blank suitcase logo on a member's ID card indicates that the patient has traditional, POS, or HMO benefits delivered through the BlueCard program.
  • A PPO in the suitcase logo indicates the patient has PPO benefits.

If the member's ID card has an alpha prefix (with or without a suitcase logo), send it to your local Blue plan—BCBSRI. It will be paid at the member's Blue plan's allowable. You will receive any reimbursement from your local plan.

For members of other Blue plans, you may verify membership and coverage by phone or by submitting electronic inquiries.

  • BCBSRI Provider Portal: Use the Eligibility Search by Member ID in the Patient Eligibility section of the secure portal.
  • Electronic inquiry: Submit a HIPAA 270 transaction (eligibility) to BCBSRI. The majority of BlueCard electronic inquiries are answered within 48-72 hours (Monday through Friday during regular office hours).
  • Phone: Call the telephone number on the back of the member's ID card. If that information is not available, call BlueCard Eligibility at 1-800-676-2583. You will be prompted for the member's alpha prefix and connected to the appropriate Blue Plan.

If Blue plan is primary

Submit claims to your local Blue plan—BCBSRI. Do not bill Medicare directly for any services rendered to a Medicare Advantage member.

If Medicare is primary

When Medicare is the primary payer for an out-of-area Blue plan member (e.g., Medigap plans), follow these procedures:

  1. Submit claims to your local Medicare contractor first. Do not file with Medicare and the supplemental insurer simultaneously. Be sure to include the:
    • complete HICN/MBI or patient's complete ID number
    • patient's name as it appears on the card
  2. After you receive an explanation of medical benefits (EOMB) or Medicare remittance notice (MRN), determine if the claim was automatically crossed over to the supplemental insurer:
    • If it crossed over: If the indicator on the EOMB or MRN 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 do not need to file for the Medicare supplemental benefits. The Medicare supplemental insurer will automatically pay you, if you accepted Medicare assignment. Otherwise, the member will be paid and you will need to bill the member.
    • If it did not cross over: If the EOMB or MRN does not indicate the claim was crossed-over, file the claim as you do today to BCBSRI. BCBSRI or the member's Blue plan will pay you the Medicare supplemental benefits. If you did not accept Medicare assignment, the member will be paid and you will need to bill the member

Coordination of benefits (COB) refers to how we ensure members receive benefits while preventing double payment for services when a member has coverage from two or more payers. The member's contract language explains which payer has primary responsibility for payment. Please follow the procedures below for submitting COB claims.

  • If the member has coverage with two out-of-area Blue plans
    • Send the claim to BCBSRI with the primary member ID first.
    • After you receive the explanation of benefits (EOB), send the information with a new bill to BCBSRI for secondary payment. The claim will not automatically cross-over.
  • If another carrier is the primary payer and a Blue plan is secondary
    • Bill the other carrier first.
    • Send the EOB from the other carrier with the claim to BCBSRI for secondary payment. The claim will not automatically cross-over.

Submit BlueCard claims electronically with your other BCBSRI claims or send paper claims to:

Blue Cross & Blue Shield of Rhode Island
ATTN: Claims Department
500 Exchange Street
Providence, RI 02903

Be sure to include the member's complete ID number when you submit the claim. The complete ID number includes the three-character alpha-numeric prefix. Incorrect or missing prefixes and ID numbers delay claims processing. Do not send duplicate claims.

If you are an indirect, support, or remote provider for members from multiple Blue plans, follow these claim-filing procedures:

  • If you have a contract with the member's Blue plan, file with that plan.
  • If you normally send claims to the direct provider of care, follow normal procedures.
  • If you do not normally send claims to the direct provider of care and you do not have a contract with the member's Blue plan, file with your local Blue plan—BCBSRI.
  • If you are a healthcare provider that offers products, materials, informational reports, and remote analyses or services, and you are not present in the same physical location as a patient, you are considered an indirect, support, or remote provider. Examples include, but are limited to:
    • prosthesis manufacturers
    • durable medical equipment suppliers
    • independent or chain laboratories
    • telemedicine providers

The claim submission process for international Blue plan members is the same as for domestic Blue plan members. You should submit the claim directly to BCBSRI.

Submit claims directly to the member's Blue plan instead of BCBSRI in the following situations:

  • You contract with the member's Blue plan.
  • The member's ID card does not include an alpha prefix.
  • The benefits are excluded from the BlueCard program (e.g., dental and prescription medications).
  • The member belongs to the Federal Employee Program (FEP). Please follow your FEP guidelines. When in doubt, please submit the claim to us electronically or send the paper claim to us at:
    Blue Cross & Blue Shield of Rhode Island
    500 Exchange Street
    Providence, RI 02903

Please note: Occasionally you may be asked to submit BlueCard claims directly to the member's Blue plan. For instance, there may be a temporary processing issue at BCBSRI or the member's Blue plan or both that prevents completion of claims through the BlueCard program.

  1. Once BCBSRI receives a claim, we will price the claim based on your contract with us (participating or preferred) and electronically route the claim to the member's Blue plan.
  2. The member's Blue plan adjudicates the claim and approves payment based on the member's benefits.
  3. BCBSRI will reimburse you accordingly and provide information on your payment voucher.

You should remind patients from other Blue plans that they are responsible for obtaining pre-certification/preauthorization for their services from their Blue plan. Please note: Other Blue plans’ preauthorization lists may differ from BCBSRI's.

You may also choose to contact the member's Blue plan on behalf of the member by phone.

Call the telephone number on the back of the member's ID card or BlueCard Eligibility at 1-800-676-2583. You will be prompted for the member's alpha prefix and connected to the appropriate Blue plan. Ask to be transferred to the utilization review area.

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