In a continuing effort to reduce administrative costs and improve claim turnaround, Blue Cross and Blue Shield of New Mexico and HMO New Mexico require complete CMS-1500 information on all claims, including National Provider Identifier (NPI). Incomplete claim forms will be returned to you for required information.
This section describes both hard-copy and electronic claims submission processes. For those provider offices that are not submitting claims electronically, we encourage you to consider this faster, easier, and more accurate method for claims submission. We would be happy to help you make this transition. See Electronic Commerce for more information on filing claims electronically.
The BlueCard Program links participating health care providers and the independent Blue Cross and Blue Shield Plans across the country and around the world through a single electronic network for claims processing and reimbursement.
The program allows you to submit claims for patients from other domestic and international Blue Cross Blue Shield Plans directly to your local Blue Plan. Your local Blue Plan will be your contact for claims payment, problem resolution, adjustments, and inquiries.
This section identifies the policies and procedures for dispute resolution that providers have a contractual obligation to follow. Here is a list of operational issues that may be identified as areas of concern for providers participating with BCBSNM:
• Disputes regarding claims
• Determination of medical necessity
• Contract issues, including contractual language, reimbursement, termination, and credentialing/quality issues
• Quality of care issues
• Potential cases of fraud
For more information about claim submission, see Section 4 of the Provider Reference Manual.
For more information about the appeals process, see Section 11 of the Provider Reference Manual.
