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Medical Policy, Clinical UM Guidelines, and Pre-Cert Requirements

View requirements for Local Plan and BlueCard Out-of-Area members.

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Traditional Medicare-Related Claims

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The following are guidelines for the processing of traditional Medicare-related claims: 
When Medicare is primary payor, submit claims to your local Medicare intermediary.
After you receive the Remittance Advice (RA) from Medicare, review the indicators:
If the indicator on the RA shows that the claim was crossed-over, Medicare has submitted the claim to the appropriate Blue Plan and the claim is in progress. You can make claim status inquiries for supplemental claims through BCBSGa.
If the claim was not crossed over, submit the claim to the BCBSGa along with Medicare remittance advice. You can make claim status inquiries for supplemental claims through BCBSGa.
If you have any questions regarding the crossover indicator, please contact the Medicare intermediary.
 
Note to Plans: all claims are expected to cross-over effective January 1, 2008 and this section will be updated accordingly after January 1.
Do not submit Medicare-related claims to BCBSGa, which is your local Blue Plan, before receiving an RA from the Medicare intermediary.
If you use Other Carrier Name and Address (OCNA) number on a Medicare claim, ensure it is correct for the member’s Blue Plan. Do not automatically use the OCNA number for BCBSGa or create an OCNA number of your own. In addition, do not create alpha prefixes. For an electronic HIPAA 835 (Remittance Advice) request on Medicare-related claims, contact BCBSGa.
Do not send duplicate claims. First check a claim’s status by contacting BCBSGa by phone or through an electronic HIPAA 276 transaction (claim status request).
 
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