Wiki BCBS Local Plan Question

[andersona1229]

I work for an independent laboratory that has an ordering provider who straddles a state line. We're getting a bit of pushback regarding what would decide the local plan from the ordering provider because their NPI is registered in one state but the specimens are being ordered and obtained in the neighboring state. We're trying to find something that will better explain what constitutes the local plan. Everything we're finding isn't exactly clear as it states where the "referring/ordering provider is located" which could mean either where they're practicing out of or, it could be argued, where the NPI is registered to. We have confirmed that it isn't overlapping service areas. As far as our billing practices for this go, we would be billing the local plan for where the specimen was obtained regardless of where their NPI is registered.

Question is, will their NPI being registered in another state impact who the local plan is and where can we find documentation for that to assuage their concerns?

 

[SMatsu]

I work for an independent laboratory that has an ordering provider who straddles a state line. We're getting a bit of pushback regarding what would decide the local plan from the ordering provider because their NPI is registered in one state but the specimens are being ordered and obtained in the neighboring state. We're trying to find something that will better explain what constitutes the local plan. Everything we're finding isn't exactly clear as it states where the "referring/ordering provider is located" which could mean either where they're practicing out of or, it could be argued, where the NPI is registered to. We have confirmed that it isn't overlapping service areas. As far as our billing practices for this go, we would be billing the local plan for where the specimen was obtained regardless of where their NPI is registered.

Question is, will their NPI being registered in another state impact who the local plan is and where can we find documentation for that to assuage their concerns?

What are the two states?

Anthem/BCBS/Any variation of those two should all follow the same guidelines for ancillary claims.

• Independent Clinical Laboratory (LAB)- File the claim to the Plan in the service area where the specimen was drawn.
  • If the referring provider is not located in the state where the specimen was drawn, file the claim to the Plan in the state where the referring provider is located.

 

[andersona1229]

What are the two states?

Anthem/BCBS/Any variation of those two should all follow the same guidelines for ancillary claims.

• Independent Clinical Laboratory (LAB)- File the claim to the Plan in the service area where the specimen was drawn.
  • If the referring provider is not located in the state where the specimen was drawn, file the claim to the Plan in the state where the referring provider is located.

That's what myself and the BCBS person in my office kept pulling up but we were still getting push back from the ordering provider. We ended up sending multiple states BCBS provider manuals (not just the two states in question) to get the point across. I'm pretty sure the ordering provider understood after that point because we haven't heard anything since. I'm just slightly salty that they didn't take our word on it the first time, but it is what it is.

It was South Carolina & Georgia.