BlueCross BlueShield of Louisiana

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BlueCross BlueShield of Louisiana Eligibility / Benefits Table of Contents

BlueCross BlueShield of

Louisiana

Eligibility / Benefits

Guide to PC-Based Transactions

Subscriber v2.0

Dependent v2.0

12.15.2006

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This publication is the proprietary property of Emdeon and is furnished solely for use pursuant to a license agreement giving the user the right to use the Emdeon product(s) referenced in this document. All uses of this document are subject to the terms of such license agreement. This document may not be used except as permitted by such license agreement or changed, copied, photocopied, reproduced, translated, or reduced to any electronic medium or machine readable form without the prior consent of Emdeon. Copyright is held by Emdeon Business Services, LLC.

Emdeonis not liable for any losses or damages that result from the use of this material, including loss of profit or indirect, special, or consequential damages.

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Overview

About the Transaction

The BlueCross BlueShield of Louisiana transaction allows you to verify a patient’s eligibility status for a single date of service.

Date of Service Restrictions

• Up to two years in the past.

• Future dates not allowed.

National Provider Identifiers

In order for you to use a National Provider Identifier (NPI) as the provider ID, the following conditions must exist:

• The payer must be ready to accept NPI. Consult our payer lists at

• The inquiring provider must have fulfilled all of the payer’s NPI registration requirements.

Customer Support

Emdeon Customer Support

800.333.0263

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BlueCross BlueShield of Louisiana Eligibility / Benefits Requests

Requests

Search Types

Subscriber Eligibility

• The provider ID of the inquiring provider.

• The patient’s BlueCross BlueShield of Louisiana subscriber identification number.

• The patient’s last name.

• The patient’s first name.

• The patient’s date of birth.

• The patient’s gender.

• The date of service.

Dependent Eligibility

• The provider ID of the inquiring provider.

• The patient’s BlueCross BlueShield of Louisiana subscriber identification number.

• The patient’s last name.

• The patient’s first name.

• The patient’s date of birth.

• The patient’s gender.

• The date of service.

Input Prompts

Prompts are listed in alphabetical order.

Account #

Requirement: Optional; not sent to the payer.

The account number you have assigned to this account, for your internal use only.

Amount

Requirement: Optional; not sent to the payer.

The amount of the claim, for your internal use only.

Date Of Birth

Requirement: Required.

The subscriber’s date of birth, in MMDDCCYY format.

Date Of Service

The date of service, in MMDDYY or MMDDCCYY format.

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BlueCross BlueShield of Louisiana Eligibility / Benefits Requests

Dep First

Used in: Dependent transactions only. Requirement: Required.

The dependent’s first name.

Dep Last

Used in: Dependent transactions only. Requirement: Required.

The dependent’s last name.

Gender

The member's gender. Choose a value from the drop-down list.

Provider ID

The provider ID of the inquiring provider.

In order for you to use the National Provider Identifier (NPI), the payer must be ready to accept NPI. Additionally, the payer’s NPI registration requirements must be fulfilled.

Sub First

Used in: Subscriber transactions only. Requirement: Required.

The subscriber’s first name.

Sub Last

Used in: Subscriber transactions only. Requirement: Required.

The subscriber’s last name.

Subscriber ID

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BlueCross BlueShield of Louisiana Eligibility / Benefits Responses

Responses

About Your Responses

All of the items described in the following response explanation may not appear in every response. Payers typically return only the information that is applicable to your query.

If the payer does not return a particular piece or section of information in a specific response, the headings for that information will not print. Items will shift position to fill the vacancy.

Your username appears in the upper left corner of the response. See your product User’s Guide for information about creating usernames.

More information about your response can be found in the following documents:

Additional Reference Documents

• PC-Standard-Eligibility-Response-Dictionary.pdf – gives a more detailed description of

data fields returned in the standard Emdeon response.

• Dictionary-of-Transaction-Error-Messages.pdf – a complete dictionary of error messages. • Common Response Abbreviations.pdf – common abbreviations used in the standard

Emdeon response, along with their full description.

These documents are available on your installation CD, and on the Web at:

Note: The above documents are in Portable Document Format (.pdf). You must have the Adobe®

Acrobat®_{Reader to view this document. If you do not have the Reader, you can download it for free at}

Status

Closed

The patient is eligible or is on file. Read the response for clarification.

Retry

The patient is ineligible or is not on file, or you entered invalid information, or Emdeon did not receive a valid standard response. Read the message in the response for clarification.

Error

A communications-related error or error of greater severity occurred. Read the message in the response for clarification.

Indicators

This information appears on the top of the report. The indicators show the following:

Benefit

Indicates the presence or type of benefit information in the response.

Y = Benefit information exists N = No benefit information exists P = Pending

Q = QMB S = Spenddown

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Other Payer

Indicates the patient’s Other Payer coverage.

Y = Patient has Other Payer coverage.

NA = Unable to determine if Other/Additional Payer information is present in the response

from the payer.

Medicare

Indicates the patient’s Medicare coverage.

A = Patient has Medicare Part A coverage. B = Patient has Medicare Part B coverage.

A&B = Patient has Medicare Parts A and B coverage.

NA = Unable to determine if Medicare information is present in the response from the payer.

Input and Response Information

The input area shows the data you sent in the request. For some of the input fields, the response area displays what the payer actually has on file. This arrangement enables you to verify what you entered against what is on file.

Depending on your software product and report settings, response information fields can appear in one of two locations:

• They can appear in a column to the right of the input fields.

• They can appear beneath the input fields, with the heading (On File).

An asterisk to the left of an input field indicates that the mirrored response data did not match your input data.

The following response fields are displayed:

- The patient’s BlueCross BlueShield of Louisiana subscriber ID. - The patient’s date of birth.

- The patient’s last name. - The patient’s first name.

Transaction Information

The Transaction Information section returns reference information for this particular transaction, such as:

- The Submit ID used for tracking.

- The date and time when the transaction was created. - Benefit Indicator:

Y = Benefit information exists. N = No benefit information exists. P = Pending.

Q = QMB. S = Spenddown.

- Medicare Indicator:

A = Patient has Medicare Part A coverage. B = Patient has Medicare Part B coverage.

A&B = Patient has Medicare Parts A and B coverage. NA = Unable to determine Medicare coverage.

- Other Payer Indicator:

Y = Patient has other payer coverage.

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Information Source

Information about the payer, such as primary ID and name.

Information Source Contact

Payer contact information.

Information Receiver

Information about the requesting provider, such as primary ID and name.

Subscriber

Information about the subscriber, or the patient, when the patient is the subscriber. Includes: - The transaction audit (trace) numbers and origins.

- The subscriber’s primary ID. - Demographic information, such as:

Last, first, middle name Date of birth

Gender

- Whether any identifying elements for the subscriber have changed from those submitted in the request (Change).

Subscriber Additional ID

An identification number other than or in addition to the member identification number for the subscriber, such as the Medicare HIC, when used in addition to the payer’s primary ID. The type of identification number is also described.

Subscriber Date

A date or range of dates relating to the subscriber’s eligibility/benefits. The type of date is also

described. If the type of date returned in this section is Eligibility, Eligibility Begin, Eligibility End,

Admission, or Service, it is implied that the date applies to all Eligibility/Benefit sections that follow

unless there is a specific date in the Eligibility/Benefit section.

Patient

Information about the patient, when the patient is a dependent. Includes: - The transaction audit (trace) numbers and origins.

- The dependent’s primary ID. - Demographic information, such as:

Last, first, middle name Date of birth

Gender

- Whether any identifying elements for the subscriber have changed from those submitted in the request (Change).

Patient Additional ID

An identification number other than or in addition to the member identification number for the patient, such as the Medicare HIC, when used in addition to the payer’s primary ID. The type of identification

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This section is returned when the patient is not the subscriber (for example, a spouse or dependent).

Patient Date

A date or range of dates relating to the patient’s eligibility/benefits. The type of date is also described. If the type of date returned in this section is Eligibility, Eligibility Begin, Eligibility End, Admission, or Service, it is implied that the date applies to all Eligibility/Benefit sections that follow unless there is a specific date in the Eligibility/Benefit section.

This section is returned when the patient is not the subscriber (for example, a spouse or dependent).

Eligibility/Benefit

Each Eligibility/Benefit section gives details about the patient’s eligibility status and other types of benefits. There can be several Eligibility/Benefit sections. Information includes:

- Eligibility Type: Identifies the type of information to which this section applies. The following types can appear:

Actv Cvg – Active Coverage Inactv – Inactive

Co-Ins – Co-Insurance Co-Pay – Co-Payment Ded – Deductible Limitations

PCP – Primary Care Provider

Pre-existing Cond – Pre-existing Condition - Coverage type.

- Service types (see “Service Types” on page 9). - Insurance types. The following types can appear:

Grp Pol – Group Policy Indiv Pol – Individual Policy - Plan coverage information.

- Benefit period. - Benefit quantity.

- Authorization or certification required. - In-network indicator.

- Product or service ID. - Procedure Modifiers.

- Health care service delivery details. - Additional identifiers.

- Benefit-specific eligibility dates. - Limitations.

- Information used to determine eligibility.

- Benefit-related entity and entity contact information.

For a complete description of the abbreviations appearing in this section, see Common Response

Abbreviations.pdf on your installation CD and on the Web at

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Error Messages

Transaction-related error messages begin with CL, HT, RH, or another alphabetic prefix, followed by a number and a line or so of text.

For a comprehensive description of all error messages, see the document Dictionary of Transaction

Error Messages.

This document is available on your installation CD, and on the Web at:

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BlueCross BlueShield of Louisiana Eligibility / Benefits Values

Values

Service Types

The payer can return any of the service types listed below.

Code Response Abbreviations Full Description

1 Med Care Medical Care

2 Surg Surgical

3 Consultation Consultation

4 Dx X-Ray Diagnostic X-Ray

5 Dx Lab Diagnostic Lab

6 Radiation Thrpy Radiation Therapy

7 Anesth Anesthesia

8 Surg Asstnce Surgical Assistance

9 Other Medcl Other Medical

10 Blood Charges Blood Charges

11 Used DME Used Durable Medical Equipment 12 DME Purchase Durable Medical Equipment Purchase 13 Amb Svc Ctr Facility Ambulatory Service Center Facility 14 Renal Supplies in the Home Renal Supplies in the Home 15 Alternate Method Dial Alternate Method Dialysis 16 CRD Equipment Chronic Renal Disease (CRD)

Equipment

17 Pre-Admin Testing Pre–Admission Testing

18 DME Rent Durable Medical Equipment Rental 19 Pneumonia Vaccine Pneumonia Vaccine

20 Second Surg Opinion Second Surgical Opinion 21 Third Surg Opinion Third Surgical Opinion

22 Social Work Social Work

23 Dx Dntl Diagnostic Dental

24 Periodontics Periodontics

25 Restorative Restorative

26 Endodontics Endodontics

27 MFP Maxillofacial Prosthetics

28 Adjunctive Dntl Svcs Adjunctive Dental Services 30 Health Bene Plan Cvg Health Benefit Plan Coverage 32 Plan Waiting Period Plan Waiting Period

33 Chiropractic Chiropractic

34 Chiropractic Office Visits Chiropractic Office Visits

35 Dntl Care Dental Care

36 Dntl Crowns Dental Crowns

37 Dntl Accident Dental Accident

38 Orthodontics Orthodontics

39 Prosthodontics Prosthodontics

40 Oral Surg Oral Surgery

41 Routine (Preventive) Dntl Routine (Preventive) Dental

42 HHC Home Health Care

43 HH Rxs Home Health Prescriptions

44 HH Visits Home Health Visits

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46 Respite Care Respite Care

47 Hosp Hospital

48 Hosp – IP Hospital – Inpatient

49 Hosp – Room/Board Hospital – Room and Board

50 Hosp – OP Hospital – Outpatient

51 Hosp – Emergency Accident Hospital – Emergency Accident 52 Hosp – Emergency Medical Hospital – Emergency Medical 53 Hosp – Ambulatory Surg Hospital – Ambulatory Surgical

54 LTC Long Term Care

55 Major Medical Major Medical

56 Medical Related Transport Medically Related Transportation 57 Air Transportation Air Transportation

58 Cabulance Cabulance

59 Licensed Ambulance Licensed Ambulance 60 General Benefits General Benefits

61 IVF In–vitro Fertilization

62 MRI/CAT Scan MRI/CAT Scan

63 Donor Procedures Donor Procedures

64 Acupuncture Acupuncture

65 Newborn Care Newborn Care

66 Pa Pathology

67 Smoking Cessation Smoking Cessation 68 Well Baby Care Well Baby Care

69 Maternity Maternity

70 Transplants Transplants

71 Audiology Exam Audiology Exam

72 Inhalation Thrpy Inhalation Therapy

73 Dx Medical Diagnostic Medical

74 Private Duty Nursing Private Duty Nursing 75 Prosthetic Device Prosthetic Device

76 Dial Dialysis

77 Otological Exam Otological Exam

78 CH Chemotherapy

79 Allergy Testing Allergy Testing

80 Immunizations Immunizations

81 Routine Physical Routine Physical

82 FP Family Planning

83 Infertility Infertility

84 Abortion Abortion

85 AIDS AIDS

86 Emergency Svcs Emergency Services

87 Cancer Cancer

88 Pharm Pharmacy

89 Free Standing Rx Drg Free Standing Prescription Drug 90 Mail Order Rx Drg Mail Order Prescription Drug 91 Brand Name Rx Drg Brand Name Prescription Drug 92 Generic Rx Drg Generic Prescription Drug

93 Podiatry Podiatry

94 Podiatry – Office Visits Podiatry – Office Visits 95 Podiatry – Nursng Home Vsts Podiatry – Nursing Home Visits 96 Professional (PHY) Professional (Physician)

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98 Prof (PHY) Visit – Office Professional (Physician) Visit – Office 99 Prof (PHY) Visit – IP Professional (Physician) Visit – Inpatient A0 Prof (PHY) Visit – OP Professional (Physician) Visit –

Outpatient

A1 Prof (PHY) Vst – Nursng Hme Professional (Physician) Visit – Nursing Home

A2 Prof (PHY) Visit – SNF Professional (Physician) Visit – Skilled Nursing Facility

A3 Prof (PHY) Visit – Home Professional (Physician) Visit – Home

A4 PC Psychiatric

A5 PC – Room/Board Psychiatric – Room and Board

A6 Psychotherapy Psychotherapy

A7 PC – IP Psychiatric – Inpatient

A8 PC – OP Psychiatric – Outpatient

A9 Rehab Rehabilitation

AA Rehab – Room/Board Rehabilitation – Room and Board AB Rehab – IP Rehabilitation – Inpatient AC Rehab – OP Rehabilitation – Outpatient

AD OT Occupational Therapy

AE Physical Medicine Physical Medicine

AF Spch Thrpy Speech Therapy

AG Skilled Nursing Care Skilled Nursing Care

AH Sklled Nrsng Cre – Rm & Brd Skilled Nursing Care – Room and Board

AI SA Substance Abuse

AJ Alcoholism Alcoholism

AK Drg Addiction Drug Addiction

AL Vision (Optometry) Vision (Optometry)

AM Frames Frames

AN Routine Exam Routine Exam

AO Lenses Lenses

AQ Nonmedical Ncessry Physical Nonmedically Necessary Physical AR Experimental Drg Thrpy Experimental Drug Therapy BA Independent Medical Eval Independent Medical Evaluation BB Prtl Hospitalization (PC) Partial Hospitalization (Psychiatric) BC Day Care (PC) Day Care (Psychiatric)

BD Cognitive Thrpy Cognitive Therapy

BE Massage Thrpy Massage Therapy

BF Pulmonary Rehab Pulmonary Rehabilitation BG Cardiac Rehab Cardiac Rehabilitation

BH Peds Pediatric BI Nursery Nursery BJ Skin Skin BK Orthopedic Orthopedic BL Cardiac Cardiac BM Lymphatic Lymphatic BN GI Gastrointestinal BP Endocrine Endocrine BQ Neuro Neurology BR Eye Eye

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BlueCross BlueShield of Louisiana Eligibility / Benefits Index