CurrentBlue Cross Blue Shield - IowaPolicy H5900-001; H5900-004; H5900-006; H5900-007; H5900-008

Blood and Blood Components

This policy governs coverage, payment, billing and member cost-sharing for blood and blood components furnished to members of Blue Cross Blue Shield - Iowa Wellmark Advantage Medicare plans (Iowa and South Dakota). It applies to inpatient and outpatient settings and aligns with Original Medicare benefit rules unless enhanced by the MA plan.

Policy Summary

PayerBlue Cross Blue Shield - Iowa

PolicyBlood and Blood Components

Policy CodePolicy H5900-001; H5900-004; H5900-006; H5900-007; H5900-008

Change TypeNo material change — informational update only

Effective DateJan 1, 2022

Next Review DateN/A

Key ActionBill claims using CMS 1500, UB-04 or 837 equivalents and report CPT/HCPCS and diagnosis codes to highest specificity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

IA & SDGeographic scope

Covers first unitFirst-unit coverage

Medicare IPPS/OPPSPayment basis

ProhibitedBalance-billing

Coverage and Payment Criteria

Policy Summary

PayerBlue Cross Blue Shield - Iowa

PolicyBlood and Blood Components

Policy CodePolicy H5900-001; H5900-004; H5900-006; H5900-007; H5900-008

Change TypeNo material change — informational update only

Effective DateJan 1, 2022

Next Review DateN/A

Key ActionBill claims using CMS 1500, UB-04 or 837 equivalents and report CPT/HCPCS and diagnosis codes to highest specificity.

SourceLink

On This Page

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Coverage criteria

Covered when ALL of the following are met:

Service is the provision of whole blood, packed red blood cells (RBCs), or other blood components (including storage and administration) provided in an inpatient or outpatient setting.

ALL of the following

Provider eligibility: provider must meet eligible-provider requirements consistent with Original Medicare.
Payable location: service is furnished in an inpatient or outpatient facility.
Frequency: furnished as medically necessary each calendar year (no specified numeric limit).
Diagnosis and age: no diagnosis or age restrictions apply.

ALL of the following

Coverage begins with the first pint of whole blood or the first unit of packed RBCs or other blood components when medically necessary (WMAHP provides full coverage beginning with the first unit).
WMAHP removes the Original Medicare replacement obligation for the first three pints/units: members are not required to replace the first three pints/units and providers may not charge members for failing to do so.

Payment: provider will be paid based on Medicare IPPS or OPPS depending on setting; this payment represents payment in full and providers may not balance-bill members.

Coding, Billing, and Deductible Rules

inv-03: Blood deductible/first-units rule 6 Original Medicare vs WMAHP first-unit coverage rule

Original MedicareOriginal Medicare applies a 'first three pints' deductible: the first three pints of whole blood or equivalent packed RBC units in a calendar year are subject to a replacement deductible (beneficiary must replace or pay) — other blood components (platelets, plasma, gamma globulin, serum albumin, fibrinogen) are not subject to the blood deductible.

Wellmark Advantage Health Plan (WMAHP) First-Unit CoverageWMAHP provides full coverage beginning with the first pint/unit for medically necessary blood and blood components in both inpatient and outpatient settings. The member is released from replacement obligation and any provider charge for the first three pints/units when WMAHP covers the first three units.

Conditions for PaymentEligible provider and payable locations follow Original Medicare. Frequency is as medically necessary each calendar year. Diagnosis and age restrictions: none.

Conditions for Payment and Provider Responsibilities

Documentation Required

Conditions for Payment — provider, setting, frequency

Eligible providers: follow the same provider eligibility rules as Original Medicare for provision of blood and blood components. Payable location: services are payable when furnished in either an inpatient or outpatient facility. Frequency: blood and blood components are payable when medically necessary, with frequency determined each calendar year. Diagnosis and age restrictions: there are no diagnosis or age restrictions for payment.

Eligible provider — Consistent with Original Medicare.
Payable location — Inpatient or Outpatient facility.
Frequency — As medically necessary each calendar year.
Diagnosis restrictions — No restrictions apply.
Age restrictions — No restrictions apply.

Definitions and Deductible Details

Original Medicare first-three-pints deductible definition — fallback explanation of blood deductible

Definition of blood deductible (Original Medicare)The first three pints of whole blood or equivalent units of packed RBCs in a calendar year are treated as a deductible in the form of replacement unless provided/replaced by someone else.

Scope — settingsApplies to units furnished under Parts A and B combined (inpatient and outpatient settings).

ExclusionsOther blood components covered as biologicals (platelets, fibrinogen, plasma, gamma globulin, serum albumin) are not subject to the blood deductible under Original Medicare.

Effect of replacementIf the provider does not obtain the first three units, the patient is not responsible for payment or replacement; refusal to accept safe offered replacement generally prevents charging the beneficiary for the unit.