Horizon Blue Cross Blue Shield New Jersey (Commercial) - Quick Reference, What You Need to Know...
Search Options
-
Basically, there are no changes in search options. This payer supports
only a single search option.
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 an inquiry to use either
a subscriber or dependent loop, depending on the specified value of the
relationship code.
Dates
-
This payer uses a single begin date for an
inquiry.
-
This payer supports up to 18 months in the
past. In other words, past dates up to 18 months prior to
January 1st of the current year. No future dates or date spans are
allowed.
-
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 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, and Mental Health – MH.
-
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
5010 response now returns service type codes for Chiropractic – 33
and Vision Benefits – AL
where applicable.
-
For
some service types, the response returns “Active” (EB01=1) along
with message text
“ SERVICE TYPE SPECIFIC BENEFITS ARE UNAVAILABLE.”
-
Some
plans are returning the benefit detail (for the new service types of
BY, BZ, and MH) in
an EB segment (EB01=D) followed by message text with the benefit
details.
For example, the MSG01 starts with “ELIGIBILITY BENEFIT….”
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.