BlueCard® Alert: Prior Authorization Process for California Blue Plan Members with Prefix PHU
Posted April 29, 2020
Some Blue Shield of California members have coverage from their employer, Prime Healthcare, a California-based health system with facilities in 14 states. You can identify these members by the Prime Healthcare logo and the three-character prefix PHU on their Blue Shield of California ID card.
Under the BlueCard program, Prime Healthcare employees or their dependents with Blue Shield of California health insurance, may seek emergency care at your facility. Please note that, once these members are stabilized, you must contact Prime Healthcare for authorization prior to rendering services. If prior authorization is not obtained from Prime Healthcare, your facility is not allowed to bill the patient for the cost of any post-stabilization care.
Typically, you would use our online routing tool to enter the out-of-area member prefix to be routed to the member’s home plan website. In this case when you enter the member’s prefix, PHU, you will be routed to a general page on the Blue Shield of California website. To save you time, here is the direct number for Prime Healthcare for authorization and appeals of prior authorization service denials: 877-234-5227.
BCBSIL BlueCard Reminder Checklist
The BlueCard program is designed to help Blue Cross and Blue Shield members take their coverage with them when they travel. It also offers providers access to an electronic network for claim submission and reimbursement. As a result, while you may see multiple patients from out-of-area Blues Plans, you still have one source for claim filing in most instances – your local Blue Plan. For Illinois providers, that’s BCBSIL.
- Verify the member’s eligibility, benefits and copayments. For faster results, check coverage electronically through the Availity® Provider Portal, or your preferred web vendor. This step will help you verify coverage and other important details, such as prior authorization requirements and vendors, if applicable. If you don’t have online access, call the BlueCard Eligibility® line at 800-676-BLUE for out-of-area member information. If prior authorization is required, you will be routed appropriately according to details of the member’s home plan.
- When recording the member ID number, be sure to include the three-character prefix. This prefix indicates the member’s group information.
- Submit BlueCard claims to BCBSIL electronically. Do not submit duplicate claims.
- Check claim status online. Check the status of the original claim online by submitting an electronic claim status request to BCBSIL via Availity or your preferred vendor portal. For more in-depth information to assist you when you are filing claims for out-of-area members, refer to the BlueCard Program Provider Manual.
Checking eligibility and/or benefits information is not a guarantee of payment. The fact that a service has been preauthorized/pre-notified is not a guarantee of payment Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage applicable on the date services were rendered. If you have any questions, please call the number on the member’s ID card.
Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSIL. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Availity. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly.