Empire
Blue Cross Blue Shield (Commercial) - Quick Reference, What You Need to Know...
Search Options
-
Previously, this payer supported two search options.
Now, only a single search option is used with a specified value for the
relationship code.
1. Provider, Date,
Subscriber ID, Patient Last Name, Patient First Name, Patient Date of
Birth, and Relationship to Subscriber.
- A
prefix should be included with the Subscriber ID to improve response
matching.
- 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.
- The
Subscriber’s Address is not returned on some commercial responses, when
previously, it was returned in 4010.
Dates
-
Only the current date is used for an
inquiry.
-
Previously, this payer supported up to one
year in the past and date spans up to 90 days.
-
Dates now reference a Plan Date - 291
(DTP01). However, in some cases, the Enrollment Date – 382,
is still being returned with the original effective date. 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.
-
The
new response provides a Plan Network Identification Number – N6.
However, the Prior Identifier Number – Q4, is no longer used.
-
For
Hospital Co-Payment and Co-Insurance, an unnecessary repeat of the
payer’s name occurred.
-
Some
Group Names and Group Numbers have been removed in the 5010
response.
-
Added
benefits and service type for Urgent Care – UC.
-
The
new response removes the $0 amount for out-of-pocket maximum.
-
In a
few cases, 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)
-
Previously, coding for Primary Care Physician (PCP) was designated
as Active Coverage – 1.
Now, the PCP coding specifies Primary Care Provider – L. (EB01)
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.