Guidelines for Ancillary Claims Filing (Lab, DME, and Specialty Pharmacy)
All Blues plans are mandated by the Blue Cross Blue Shield Association (BCBSA) to use the following guidelines when submitting ancillary claims for Independent Clinical Lab, Durable/Home Medical Equipment and Supplies (DME), and Specialty Pharmacy providers:
- 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.
- Durable/Home Medical Equipment and Supplies (DME) - File the claim to the Plan in the service area where the equipment was shipped.
- If purchased from a retail store, file the claim to the Plan in the state where the purchase was made.
- Starting December 1, 2020, CareFirst will conduct a post-adjudication audit for procedure codes allowed at a percent of charge. For more information, view CareFirst's DME Percent of Charge Policy.
- Specialty Pharmacy - File the claim to the Plan in the service area where the ordering physician is located.
- CareFirst does not include Home Infusion Therapy (HIT) as an ancillary claim type for Specialty Pharmacy.
View a chart of claims filing examples .
Important: In order to be paid for claims, we encourage you to contract with each Blues Plan to which you file claims.
If a claim is submitted to CareFirst and rejected, the following codes will appear on the electronic remittance advice (ERA-835) or paper voucher:
View the Service area zip code list .
What To Do
|Independent Clinical Laboratory||N557||The claim/service is not payable under our service area.||The claim/service is not payable under our service area.|
|DME Supplier||N558||The claim/service is not payable under our service area.||File the claim to the Payer/Plan in whose service area the equipment was received.|
|Specialty Pharmacy||N559||The claim/service is not payable under our service area.||File the claim to the Payer/Plan in whose service area the ordering physician is located.|
If an electronic claim is submitted in error, you will receive the Health Care Claim Status Code: 116 - Claim submitted to incorrect Payer.
Verifying Member Eligibility
The following can be used to verify ancillary benefits and member eligibility.
- CareFirst Direct (Providers located in the CareFirst service area only.)
- CareFirst on Call - (202) 479-6560/(800) 842-5975
- Call (800) 676-BLUE