Premera Blue Cross (Commercial) - Quick Reference, What You Need to Know...
Search Options
-
As before this payer supports 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
-
As before, only a single begin date is
used for an inquiry.
-
This payer supports dates up to two years
in the past. No future dates or date spans are allowed.
-
Inquiry dates now reference a Plan Date
291 (DTP01)
-
The response returns a Plan Date 291
and/or Plan Begin Date 346. (2100C Loop, DTP Segment)
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, Mental Health MH, and Urgent
Care UC.
-
Now,
this payer exclusively uses a W for both In Plan and Out of Plan
Network (EB12=W).
-
The
primary difference between the 4010 and 5010 responses is that the
4010 response contained
Message Segments (MSG) that are now codified in the 5010 response.
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.