As a reminder, ancillary claims are filed with the local plan as follows:
Lab provider: The location of the referring provider is where the rendering lab needs to submit the claim.
- For example: A member’s PCP is located in Seekonk, Massachusetts, but gets their blood drawn at a laboratory in Rhode Island. The Rhode Island laboratory has to submit the claim to Blue Cross & Blue Shield of Massachusetts.
Durable/home medical equipment providers: Where the equipment or supply is delivered or purchased at a retail store.
Specialty pharmacy providers: Where the ordering physician is located.
The ancillary claims filing rules apply to the following ancillary providers:
- Independent clinical laboratories
- Durable and home medical equipment (DME or HME) and supply providers
- Specialty pharmacies
Plans may voluntarily enter into contracts with ancillary providers who are located outside of Rhode Island, but solely for services rendered within the plan’s exclusive service area.
Plans may not contract with ancillary providers for services their members receive outside of the plan’s exclusive service area.
- Exemplo: Blue Cross & Blue Shield of Illinois (BCBSIL) may contract with a lab located in Florida only for specimens drawn within BCBSIL’s exclusive service area.