5.2.6 Blue Cross Blue Shield (BCBS) Nonparticipating Physicians

BCBS currently has procedures in place to pay assigned claims directly to nonparticipating providers. A nonparticipating provider is eligible to receive direct reimbursement from BCBS, when assignment is accepted. However, only payment dispositions are sent to the provider. An EOB regarding denials is sent only to the client.

Be aware that by accepting assignment on a claim when the client also has the CSHCN Services Program coverage, providers are agreeing to accept payment made by insurance carriers and the CSHCN Services Program, when appropriate, as payment in full. The CSHCN Services Program client must not be held liable for any balance related to CSHCN Services Program-covered services.

Physicians who treat CSHCN Services Program clients with BCBS private insurance and who are nonparticipating with BCBS must follow the instructions and procedures as follows:

•	Do not provide the CSHCN Services Program client with a bill or anything the client could use as a bill. An informational statement may be given. To avoid confusion, write “Information only” clearly on the copy of the statement.

•	Bill BCBS directly, accepting assignment. When payment from BCBS is received, the claim may be filed with TMHP to seek additional payment up to the CSHCN Services Program allowable amount.

•	If no BCBS disposition is received within 110 days from the date the claim was billed to BCBS, file the claim to TMHP-CSHCN Services Program and furnish the following information:

•	Indicate “Nonparticipating BCBS”

•	Provide the date BCBS was billed

•	Include a statement signed and dated by the provider that no disposition was received from the TPR within 110 days from the date the claim was billed

A claim must be filed with TMHP-CSHCN Services Program within 365 days of the date of service.