The BLUES — How well do you know your payers?

Three quick questions to test your basic knowledge of the BLUES:

1.  Dr. White’s practice is located in Alabama. Sue, a patient, lives in Mississippi and her home insurance plan is Blue Shield of Mississippi.  Yesterday, she had an appointment with Dr. White.  Where should the claim should be sent?

2.  Stan lives in PA and has Blue Shield coverage from his New York employer. He sustains an injury while on vacation in Nevada.  The Nevada orthopedic physician provides medical services for Stan before he returns to PA.  Where should the claim should be sent?

3.  Dr. Smith has offices in two different states:  Maryland and Delaware.  Ronald, an employee of a New Jersey company has Blue Shield of New Jersey insurance.  Ronald typically sees Dr. Smith in the Wilmington, Delaware office.  However, due to a work emergency at a remote location, Ronald received treatment in Dr. Smith’s Maryland office which was a closer location.  Where should the claim be sent?

It’s safe to say that out of necessity, many medical practice employees wear multiple hats when it comes to supporting the increasing demands of running a busy medical  practice.  For some practice functions, multi-tasking is a way of life and works just fine.  However, certain aspects, such as billing and coding, require a more dedicated approach.  In particular, understanding how to properly bill claims – especially  the Blues —  will help your practice collect what is owed and avoid denials & claim follow up.

As a Blue Cross and Blue Shield participating provider, all claims get submitted to the local plan, including local subscribers, out-of-area subscribers, primary and secondary claims.  The local plan is the one YOU, the provider are contracted to based on where you provide services.  Every claim, regardless of paper or electronic, must be submitted to the correct local plan.

In many practices, billing mistakes are made because of a lack of understanding the proper way to submit claims, especially to the Blues.  In many cases, claims are mistakenly submitted to the patient’s home plan based on their insurance card information.  This is not correct and will result in the claim being denied, not processed or possibly lost in transit.

No matter where the patient’s home plan is based, all claims must be billed to the local plan where the provider’s services are rendered.

If you are experiencing inconsistent cash flow, growing accounts receivable or increased denials, we can help.  Contact us here to schedule a FREE consultation call.

So, how did you do?  See the answers  below.


  1. Alabama
  2. Nevada
  3. Maryland