Blue Cross
Blue Shield of South Carolina (Commercial) - Quick Reference, What You Need to Know...
Search Options
- No
changes in search options or search criteria. However, maximum field
lengths for names have been extended.
As in previous transactions, the Provider Specialty is optional.
- No
changes to previous health plans for BlueChoice HealthCare and South
Carolina State Health Plan.
As in the past, these plans are handled by
separate payer mnemonics for EDI users and a drop-down selection on the
OneSource interface.
- 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.
Dates
-
Only a single date is used for an inquiry.
The response provides the beginning and ending date range which includes
the requested date.
-
No changes in date rules. However, dates now reference a Plan Date -
291 (DTP01).
Date references for Eligibility – 307, Enrollment – 382, and Service –
472 may not be returned.
Response Data
Benefits
The following information is based on a
generic “Health Benefit Plan Coverage - 30” inquiry.
-
The
country code is not returned.
-
New
Medicare Member Names and HIC Numbers are provided when the eligibly
benefit includes other or additional payers. The Contracted Service
Provider is also returned.
-
New
response detail is provided on hospital per visit co-payments for
some PPO members.
-
New
Pharmacy benefit manager and vendor information is returned for some
PPO members.
-
The
new response does not provide a zero percentage value for
co-insurance as in previous transactions. This provides a clean
response that is less confusing.
-
PCP
names and NPI values have been added to the response.
-
Psychiatric Inpatient and Psychiatric Outpatient is not returned.
-
Additional information is provided for Chiropractic - 33, Physicians
Visit Office Sick - BY, Physicians Visit Office Well - BZ, and
Urgent Care – UC.
-
The
new response may designate when benefits are the same regardless of
whether they are In Plan Network or Out of Plan-Network, or may
designate a benefit that does not apply to the Plan-Network.
-
The
new response has been shortened with respect to the number of
message texts containing lengthy explanations for particular
benefits, such as the frequency of mammograms. This provides a clean
response that is less confusing.
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.