CurrentBlue Cross Blue Shield - South CarolinaPolicy N/A

Subrogation and Workers' Compensation Questionnaire and Procedures

Describes BCBS-SC's process for identifying accident- or work-related claims, member/provider responsibilities to complete an accident/work-related questionnaire, and potential recovery or withholding of paid medical benefits.

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicySubrogation and Workers' Compensation Questionnaire and Procedures

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionProviders/members must complete and return the accident/work-related questionnaire with incident and insurer details; failure to return may result in withholding of payment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5 daysquestionnaire return timeframe

1-800-288-2227 ext. 43060contact

may withhold paymentnonresponse consequence

diagnosis-codeclaim flag trigger

Subrogation and Workers' Compensation Criteria

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Subrogation and Workers' Compensation Criteria

Covered actions and member/provider obligations when an injury or illness may be caused by a third party or is work-related.

BCBS‑SC actions and member obligations apply when an injury or illness is caused by a third party or is work-related (per member contract).

ALL of the following

Member must complete and return the accident/work‑related questionnaire within five days of receipt.
Questionnaire collects incident details, third‑party/insurer/adjuster information, and workers' compensation filing status.
If the questionnaire is not returned, BCBS may withhold payment on the member's related medical claims.

Reimbursement / Subrogation Actions (ONE or more may apply)

BCBS may seek reimbursement of medical benefits paid from the responsible third party.
BCBS may seek reimbursement from the responsible third party's insurer or the member's insurer.
If the member receives a settlement or award related to the injury, the member must reimburse BCBS for medical benefits paid.

Workers' Compensation Exclusion

BCBS will not provide benefits for services covered by workers' compensation laws for work‑related injuries or illnesses.
If a workers' compensation settlement or award is received, BCBS considers that payment to be workers' compensation and will not provide medical benefits for the injury or illness.

Claims are flagged for this review when they contain diagnosis codes indicating injury/accident per the payer's physician‑established list; flagged claims generate the questionnaire.

Diagnostic code triggers prompt the questionnaire and potential subrogation/workers' compensation review.

Applies to a broad range of third‑party liability scenarios (e.g., auto/motorcycle, premises liability, defective products, medical malpractice, food poisoning) and workplace injuries; BCBS will administer claims and seek reimbursement as warranted.

Diagnosis Code Triggers and Flagging

Accident-type diagnosis code triggersmixed

Claims are flagged when they contain diagnosis codes that indicate injury or accident-related conditions as determined by the payer's physician-established list.

Diagnosis-code flagging (claims triggers)

Trigger descriptionClaims are flagged when they contain diagnosis codes from BCBS-SC's physician-established list indicating injury or accident-related conditions.

Automatic actionWhen a processed claim contains one of these accident-type diagnosis codes, the system generates an accident/work-related questionnaire.

Source of codesList of diagnosis codes established by BCBS-SC physicians (used internally to identify potential subrogation/workers' comp cases).

Questionnaire Requirements and Payment Withholding

Documentation Required

Questionnaire Completion Requirement — complete and return within 5 days

Complete, sign, and return the accident/work-related questionnaire within five days of receipt. The form asks for incident details (date, location, description), third‑party/insurer/adjuster information for auto/other accidents, and employer/workers' compensation information if work related. Return the questionnaire to the contact shown on the form or as instructed in communications from Blue Cross and Blue Shield.

Provide date, city/county/state of injury and description of how the injury occurred (chunk 1).
For auto/motorcycle or other accidents, provide the person causing injury, their insurer, policy/claim number, adjuster name and contact (chunk 2).
For work‑related injuries, provide employer name/address, workers' compensation filing status, carrier, policy/claim number, adjuster and attorney contact if applicable (chunk 3).
Return the completed, signed form within five days of receipt (chunk 1).

Denial Risk

Potential Withholding of Payment for Non‑response

If the completed questionnaire is not returned, Blue Cross and Blue Shield may withhold payment on the member's medical claims related to the incident.

Failure to return the questionnaire can result in withholding of payment while BCBS evaluates responsibility or pursues reimbursement (chunk 10).

Key Terms

Subrogation — definition

DefinitionSubrogation is the contract clause that gives Blue Cross and Blue Shield the right to seek reimbursement of medical bills paid for an injury or illness caused by a third party from the third party, their insurer, the member's insurer, or the member if they receive a settlement.

When appliedUsed when medical benefits were paid for injuries/illnesses caused by a third party or when the member receives a settlement involving those injuries.

Recovery targetsThird parties, third‑party insurers, the member's insurer, or the member (if a settlement is received).

Workers' Compensation Exclusion

Provision summaryWorkers' compensation provision excludes payment of medical bills when workers' compensation laws cover, provide, or pay for treatment of a work-related injury or illness.

Effect of workers' comp settlementIf a member receives a workers' compensation settlement, BCBS-SC treats the settlement as workers' compensation and will not provide medical benefits for that injury or illness.

ScopeApplies to services, supplies, and treatments related to work-related accidents or illnesses covered by workers' compensation statutes.

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicySubrogation and Workers' Compensation Questionnaire and Procedures

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionProviders/members must complete and return the accident/work-related questionnaire with incident and insurer details; failure to return may result in withholding of payment.

SourceLink

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