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Back  RFI # 819: CLP06 Reporting for Blue Plans

Formal vs. Informal Help Informal Formal

Submitter

Barbara Sesny

Description

Does the note for codes 12 and 15 which is specific for Blue Plans take precedence over the assignment of these codes for PPO or indemnity insurance coverage?

For instance, we have participating providers and we have a separate PPO network. What do we report in CLP06 for non-par providers, for par- providers and for providers in the PPO network when that is the operative for the patient's coverage?

Response

This issue is explicitly addressed in guide 004010X091. The note on CLP06 code 12 states "Use this code for Blue Cross/Blue Shield par arrangements." The note on CLP06 code 15 states "Use this code for Blue Cross/Blue Shield non-par arrangements."

When the provider is not a participating provider, code 15 is to be reported in CLP06.

When the provider is a participating provider and/or a member of the PPO network, report code 12 in CLP06. The operative of the notes is that while the Blues may have a product that is named "PPO", participating providers in the Blue Plan general network are also participating in a preferred provider organization and that means reporting CLP06 as a PPO.
Submission 7/27/2009
Status Date 8/19/2009
Status F - Final
Primary References
Document 4010X091A1
Section3.1
Page92
Set ID1032