CareFirst BCBS (Commercial) - Quick Reference, What You Need to Know...
Search Options
-
No changes in search options or search criteria. However, the Patient
Last Name, First Name
and Patient Sex fields are now optional. This payer now supports the
following search option.
1. Subscriber ID, Patient
Last Name, Patient First Name, Patient Date of Birth, Patient Sex,
and
Relationship to Subscriber.
-
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
-
This payer requires only the begin date
for an inquiry. Previously, both the begin and end dates
were required.
-
This payer supports dates up to one year
in the past. No future dates or date spans are allowed.
-
Inquiry dates now reference a Plan Date –
291 (DTP01).
Response Data
Benefits
The following information is based on a
generic “Health Benefit Plan Coverage - 30” inquiry.
-
This payer only responds to an inquiry that uses the “Health Benefit
Plan Coverage – 30” service type.
-
The 5010 response returns both the Group Name and Group Number.
(2100C, REF Segments)
-
The 5010 response now returns multiple service type codes in the
eligibility benefit loop (EB03).
-
The 5010 response now uses service type codes for Physician Office
Visit Sick – BY,
Physician Office Visit Well – BZ, Mental Health – MH, and Urgent
Care – UC.
-
This payer has stopped using the “U” designation for In Plan and Out
of Plan Network (EB12=U).
Now, they extensively use a “W” for both In Plan and Out of Plan
Network (EB12=W).
-
The
previous 4010 response most likely appears to have been a “step
down” conversion of
the 5010 response now being returned. As such, this 4010/5010
comparison does not accurately
reflect all changes that may have been made to the 5010.
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.