Wellmark BCBS (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.
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
-
For an inquiry, this payer uses a single
begin date.
-
This payer supports up to two years in the
past. No future dates or date spans are allowed.
-
Dates now reference a Plan Date – 291
(DTP01). Previously, date references for Eligibility – 307 were used.
-
The response now returns the Plan Dates
using a Date Range (DTP02=RD8).
The "first date" in the range is the beginning date of a Member’s
Current Plan Period.
-
The Enrollment Date – 382 (DTP01) is no
longer returned.
Previously, this was the Original Enrollment Date for the Member.
Response Data
Benefits
The following information is based on a
generic “Health Benefit Plan Coverage - 30” inquiry. All other response
information appears unchanged or is similar to the previous response,
excepted as noted below.
-
The
5010 response now uses service type codes for Chiropractic – 33, and
Mental Health – MH.
-
The
5010 response now returns multiple service type codes in the
eligibility benefit loop (EB03).
-
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).
-
Deductibles are now returned for Medicare Supplement Plans.
-
The
Primary Care Provider’s Name is now returned in the Last Name
(NM103) and First Name (NM104)
elements of the 2120 Loop. Previously, the Primary Care Provider’s
Full Name was returned using only the
First Name (NM104) element. In other words, the Provider’s Full Name
is now separated into first and last
name values.
For example:
4010 (NM1*P3*1**ROBERT A SMITH JR MD~)
5010 (NM1*P3*1*A SMITH JR MD*ROBERT~)
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.