BlueCard home plan vs host plan

When a patient's Blue coverage comes from a plan in another area, two Blue plans are involved: the member's home plan and the local plan where care was given. Knowing which is which tells you where to send the claim, who to call with questions, and why the prefix on the ID card matters so much.

What the BlueCard program does

BlueCard is a national program that lets members of one Blue plan get health care benefits wherever they live or travel. The Blue Cross Blue Shield Association describes it as linking participating providers and the independent Blue companies through a single electronic network for claims processing and reimbursement.

For a provider, the practical effect is that you can submit claims for patients from other Blue plans, in the US and abroad, to your local Blue plan.

Home plan

The home plan is the Blue plan the member has a contract with. The member's benefits are determined by the home plan.

Host plan (local plan)

The host plan is the Blue plan in the area where the member got care. Blue Cross Blue Shield of Massachusetts, for example, says it is usually considered the local (or host) plan for care given in its area.

Where to send the claim

The plan manuals we cite tell providers to send BlueCard claims to their local plan:

• Highmark tells its providers to submit all Blue plan claims to the local Highmark plan where services were rendered.
• Blue Cross and Blue Shield of New Mexico's manual says your local plan is your sole contact for claims payment, adjustments and issue resolution.

For details such as payer IDs, portals and contact numbers, use your local plan's own provider manual.

How the prefix connects the two plans

The prefix identifies the member's Blue plan or national account, and the Blue Cross Blue Shield Association describes it as what lets the claim be routed properly. One plan's manual adds that it is critical for electronically routing specific HIPAA transactions to the right plan.

That is why the plan manuals we cite ask for the complete member ID, including the three-character prefix, on every claim, and one says claims with an incorrect or missing prefix cannot be processed. To see which plan a prefix is listed for in our data, use the prefix lookup.

Checking eligibility for out-of-area members

The plan manuals we cite point providers to BlueCard Eligibility at 1-800-676-BLUE (2583). The line routes eligibility, benefit and pre-certification or referral authorization inquiries to the member's plan, and you are asked to give the member's prefix when you call. For precertification, Highmark says the call is routed to the area that handles it at the member's home plan.

One plan's manual says the line is not for claim status. Direct claim questions to your local plan.

What is not part of BlueCard

The Federal Employee Program (FEP) is excluded from BlueCard. FEP member IDs begin with "R" instead of a three-character prefix. Follow the instructions on the FEP card.