Specialty Pharmacies

General
Policy Number: GP-P-009

Last Updated: May 24, 2022 

Specialty Pharmacies must file to the Plan in whose state the referring provider is located.  

Required fields as noted in the following chart must be populated on the claim. Claims that are missing required information will be returned to the provider.

Provider Type Required Fields Where to file
Independent Clinical Laboratory (any type of non -hospital based laboratory) Ordering Provider Name and Type I NPI Number File the claim to the Plan in whose state the specimen was drawn*   

* Where the specimen was drawn will be determined by which state the ORDERING provider is located.
Example:  

Blood is drawn* in lab or office setting located in Nebraska. Blood analysis done in Minnesota.  
File claim to: Blue Cross and Blue Shield of Nebraska.  

*Claims for the analysis of a lab must be filed to the Plan in whose state the specimen was drawn.
Durable/Home Medical Equipment and Supplies (DME/HME) Patient’s Address  
Ordering Provider Name and Type I NPI Number  
Place of Service  
Service Facility Location Information		 File the claim to the Plan in whose state the equipment was shipped to or purchased in a retail store.  

Note: Items shipped to the patient should be submitted with a POS 12 (Home). Items purchased in the retail store should be submitted with a POS 17 (Retail Clinic)

Examples:

  • Wheelchair is purchased at a retail store in Nebraska.
    File claim to: Blue Cross and Blue Shield of Nebraska. The physical location of the retail store must be populated in field 32 (Loop 2310C).
  • Wheelchair is purchased on the internet from an online retail supplier in Nebraska and shipped to Minnesota.  
    File claim to: Blue Cross and Blue Shield of Minnesota. Field 32 (Loop 2310C) should be blank.
  • Wheelchair is purchased at a retail store in Nebraska and shipped to Minnesota.   
    File claim to: Blue Cross and Blue Shield of Minnesota.  
Specialty Pharmacy Ordering Provider Name and Type I NPI Number File the claim to the Plan whose state the ordering provider is located.

Examples:

  • Wheelchair is purchased at a retail store in Nebraska.
    File claim to: Blue Cross and Blue Shield of Nebraska. The physical location of the retail store must be populated in field 32 (Loop 2310C).
  • Wheelchair is purchased on the internet from an online retail supplier in Nebraska and shipped to Minnesota.  
    File claim to: Blue Cross and Blue Shield of Minnesota. Field 32 (Loop 2310C) should be blank.
  • Wheelchair is purchased at a retail store in Nebraska and shipped to Minnesota.   
    File claim to: Blue Cross and Blue Shield of Minnesota.  
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