Highmark
Blue Cross Blue Shield (Commercial) - Quick Reference, What You Need to Know...
Search Options
-
This payer now supports three search options. Previously, only two search
options were available.
1. Subscriber ID, Patient
Last Name, Patient First Name, Patient Date of Birth, and Relationship
to Subscriber.
2. Subscriber ID, Patient Last Name, Patient First Name, and
Relationship to Subscriber.
3. Subscriber ID, Patient Date of Birth, and Relationship to Subscriber.
- This
payer does not promote dependent data. For this reason, it is necessary
for an inquiry to use
either a subscriber or dependent loop, depending on the specified value
of the relationship code.
- It
may be necessary to include a prefix when entering Subscriber ID values.
- As
before, this payer requires the designated provider type to be included
in the transaction.
- This
payer now uses different separators as in previous 4010 transactions.
Dates
-
This payer now requires both begin and end
dates. Previously, only a single date of service was used.
-
This payer supports up to two years in the
past and there are no restrictions on date spans.
No future dates are allowed. Previously, the payer allowed dates up to
six months in the future.
-
Dates now reference a Plan Date 291
(DTP01). Previously, date references for Eligibility 307 were used.
Response Data
Benefits
The following information is based on a
generic Health Benefit Plan Coverage - 30 inquiry.
-
The
5010 response now includes the Subscriber/Dependent address
information
which was not present in 4010.
-
For
deductibles and co-payments, the service types for Professional
Physician Visit Office 98 and
Professional Physician Visit Inpatient 99 have been replaced with
Physician Office Visit Sick BY and
Physician Office Visit Well BZ.
-
Highmark 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).
-
Both
Chiropractic 33 and Mental Health MH have been added to most
responses.
-
Highmark is consistently setting the Maintenance Type Code
(INS03=001) and the
Maintenance Reason Code (INS04=25). The meaning of this change is
unclear.
-
Medigap Member IDs with trailing alpha characters have been trimmed
in 5010 to exclude trailing characters.
-
Some
responses have new Other Payer/Outpatient categories with no
information about the other payer.
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.