BCBS of Georgia (Commercial) - Quick Reference, What You Need to Know...
Search Options
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No changes in search options or search criteria. However, the optional
field for Patient Sex was removed.
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This payer does not promote dependent data. For this reason, it is
necessary for a transaction to use either a subscriber or dependent
loop, depending on the specified value of the relationship code.
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No differences in the demographic information were identified.
Dates
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Only the current date is used for an
inquiry.
Previously, this payer supported both a beginning and ending date range
for an inquiry.
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Dates now reference a Plan Date – 291
(DTP01) and are returned in a range format.
Date references for Eligibility – 307, are not returned.
Response Data
Benefits
The following information is based on a
generic “Health Benefit Plan Coverage - 30” inquiry.
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This
payer now provides the Member’s Address on most response types.
(This is a valuable enhancement from the previous 4010 response).
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Inaccurate Member ID prefixes that are submitted in the inquiry are
now corrected. The original Member ID containing an incorrect prefix
is returned in a reference segment.
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This payer now provides a suffix on Group Numbers.
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Group Numbers now include two or three extra digits, when compared
to the original Group Numbers that were returned in the 4010
response.
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Response data is now provided for Urgent Care – UC.
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The
$0.00 Deductible for various service types for HMO plans is no
longer delivered in the 5010 response.
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New
Group Numbers are presented on Medicare Supplements.
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In some cases, new Coordination of Benefit (COB) payer information
is reported.
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Sporadically, benefit information is returned when the benefits are
the same for both an In Plan and Out of Plan Network, or when a Plan
Network benefit does not apply. This may occur regardless of the In
Plan or Out of Plan Network designation. (EB12=W)
Disclaimer
This document is not intended to identify every scenario that may be
presented in the payer response.
It should
also be noted, that the payer response may vary depending on the search
criteria used in the initial inquiry.
Some content
is no longer returned in the X12 5010 271 response. In a similar fashion,
some content has been
modified and
new response information may be returned. Information that appeared
consistent between the
4010 and 5010
responses was not presented in this document.