Excellus
BCBS New York (Commercial) - Quick Reference, What You Need to Know...
Search Options
-
Only a single search option is used with a specified value for the
relationship code.
1. Subscriber ID, Patient
Last Name, Patient First Name, Patient Date of Birth, 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
-
Both begin and end dates are used for an
inquiry.
-
This payer supports up to one year in the
past and date spans up to 90 days. No future dates are allowed.
-
Dates now reference a Plan Date - 291
(DTP01). In other words, the response now returns the Plan Date.
Response Data
Benefits
The following information is based on a
generic Health Benefit Plan Coverage - 30 inquiry.
-
Instead of using message (MSG) segments, the 5010 response now uses
service types for
Physician Office Visit Sick BY, Physicians Office Visit Well BZ,
Urgent Care UC, and
Mental Health MH.
-
The
5010 response now returns multiple service type codes in the
eligibility benefit loop (EB03).
-
Instead of using a message (MSG) segment, an indicator value of W
is used for both
In-Plan and Out-of-Plan Networks. In other words, when benefits are
the same for both an
In Plan and Out of Plan Network, or when a plan network does not
apply, regardless of
the 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.