BlueCross BlueShield of Massachusetts

Transcription

1 BlueCross BlueShield of Massachusetts Health Services Review Transactions Outpatient Services Review: Subscriber and Dependent v1.4 Home Health Services Review: Subscriber and Dependent v1.5 Ambulance Services Review: Subscriber and Dependent v

2 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. Emdeon is 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.

3 Table of Contents Table of Contents Overview About the Transaction Customer Support Requests Transaction Types Outpatient Services Review (Subscriber and Dependent) Home Health Services Review (Subscriber and Dependent) Ambulance Services Review (Subscriber and Dependent) Input Prompts Accident Country Accident Date Accident State Account # Amount Auto Accident Birth Date Diagnosis 2 through Diagnosis Employ Related First Name Hme Hlth PrcCde Hme Hlth PrcQual Last AdmPrd End Last AdmPrd Strt Last Name Last Visit Date Level of Service Medicare Cvg Member ID Other Party Resp Pat Dscrg FacCde Phys Contact Dte Phys Order Date Principal Diag Proc Code Proc Code Src Proc Date Procedure 2 through Procedure Procedure 2 Date through Procedure 12 Dte Procedure 2 Src through Procedure 12 Src Prognosis Req Prov Type Req Role Req Tel Requestor ID Service Type Skilled Nursing Surgery Date Svc Date Begin Svc Date End Svc Prov ID Svc Prov Type Trnsprt Code Trnsprt Dist Trnsprt Reason Emdeon Business Services LLC. All rights reserved. Page i

4 Table of Contents Visits Responses About Your Responses Status Input Information Response or (On File) Information Health Care Service Review Review Detail Error Messages Index Emdeon Business Services LLC. All rights reserved. Page ii

5 Overview Overview About the Transaction The BlueCross BlueShield of Massachusetts (BCBSMA) health care services review transactions allow you to request authorization for the following services: Outpatient Home Health Ambulance Note: You cannot cancel these transactions electronically. For cancellations, please contact BCBSMA HCC/Referral Management at or Customer Support Emdeon Customer Support Emdeon Business Services LLC. All rights reserved. Page 1

6 Requests Requests Transaction Types Outpatient Services Review (Subscriber and Dependent) Subscriber and dependent Outpatient transactions allow you to submit a request for authorization of outpatient services provided to a BCBSMA managed care member or to a subscriber of an out-of-state BCBS plan. Home Health Services Review (Subscriber and Dependent) Subscriber and dependent Home Health transactions allow you to submit a request for authorization of home health services provided to a BCBSMA managed care member or to a subscriber of an out-of-state BCBS plan. Ambulance Services Review (Subscriber and Dependent) Subscriber and dependent Ambulance transactions allow you to submit a request for authorization of ambulance services provided to a BCBSMA managed care member or to a subscriber of an out-of-state BCBS plan. Input Prompts Prompts are listed in alphabetical order. Accident Country Requirement: Situational; required if Auto Accident is Y. The country in which the accident occurred. Enter the country code or choose one from the drop-down list. Accident Date Requirement: Situational; required if Auto Accident is Y. The date on which the accident occurred, in MMDDCCYY format. Accident State Requirement: Situational; required if Auto Accident is Y. The state in which the accident occurred. Enter the state code or choose one from the drop-down list. Account # The patient s account number. For your internal use only (not sent to the payer) Emdeon Business Services LLC. All rights reserved. Page 2

7 Amount The amount of the claim. For your internal use only (not sent to the payer). Auto Accident Requirement: Situational. BlueCross BlueShield of Massachusetts Health Services Review Requests Whether or not the referral is related to an automobile accident. Choose a value from the drop-down list: Birth Date Requirement: For subscriber transactions, required for FEP members and nine-digit member IDs (nine digits following the three-character prefix), optional for eleven-digit member IDs. For dependent transactions, required for out-of-state members. The patient s date of birth, in MMDDCCYY format. Diagnosis 2 through Diagnosis 12 Up to 10 additional ICD-9-CM or ICD-10-CM diagnosis codes relating to the referral. Employ Related Requirement: Situational. Whether or not the referral is employment-related. Choose a value from the drop-down list. First Name Requirement: Optional for BCBSMA members; required for out-of-state members. The patient s first name. Hme Hlth PrcCde The HCPCS, ICD-9-CM, or ICD-10-CM code for the surgical procedure. Hme Hlth PrcQual Source of the procedure code for the surgical procedure. Choose a value from the drop-down list Emdeon Business Services LLC. All rights reserved. Page 3

8 Last AdmPrd End Requirement: Required if you entered a last admission period start date. The ending date of the patient s last inpatient admission, in MMDDYY format. Last AdmPrd Strt BlueCross BlueShield of Massachusetts Health Services Review Requests The beginning date of the patient s last inpatient admission, in MMDDYY format. Last Name Requirement: Optional for BCBSMA members; required for out-of-state members. The patient s last name. Last Visit Date The date of the patient s last visit to the physician, in MMDDYY format. Level of Service Requirement: Required for out-of-state patients. The level of service provided. Medicare Cvg Whether the patient has Medicare coverage. Choose a value from the drop-down list. Member ID The patient s member ID (three-character prefix plus the nine- or eleven-digit number). For FEP members, do not enter the three-character prefix; enter R plus the eight-digit member number. Other Party Resp Requirement: Situational. Whether or not the referral is employment related. Choose a value from the drop-down list Emdeon Business Services LLC. All rights reserved. Page 4

9 Requests Pat Dscrg FacCde The type of facility from which the patient was last discharged. Choose a value from the drop-down list. Phys Contact Dte The date of the agency s last contact with the patient s physician, in MMDDYY format. Phys Order Date The date on which the agency received verbal orders from the patient s physician for start of care, in MMDDYY format. Principal Diag The patient s ICD-9-CM or ICD-10-CM principal diagnosis code. Proc Code The primary procedure code relating to the service. For Blue Care 65 members, use the CPT-4 code. For all others, use the ICD-9 or ICD-10 code. Proc Code Src Requirement: Required if you entered a Proc Code. The source of the procedure code entered above. Choose a value from the drop-down list: BQ = CPT-4 code; use for Blue Care 65 members. BO = ID-9 or ICD-10 code; use for all other members. Proc Date Requirement: Required if you entered a Proc Code. The date of the procedure identified by the Proc Code field, in month-day-year format (MMDDYY). Procedure 2 through Procedure 12 An additional procedure code relating to the service. For Blue Care 65 members, use the CPT-4 code. For all others, use the ICD-9 or ICD-10 code Emdeon Business Services LLC. All rights reserved. Page 5

10 Procedure 2 Date through Procedure 12 Dte Requirement: Required if you entered the corresponding Procedure. BlueCross BlueShield of Massachusetts Health Services Review Requests The date of the procedure identified by the preceding Procedure field, in month-day-year format (MMDDYY). Procedure 2 Src through Procedure 12 Src Requirement: Required if you entered a Proc Code 2 through 12. The source of the procedure code(s) entered. Choose a value from the drop-down list: BQ = CPT-4 code; use for Blue Care 65 members. BO = ICD-9 or ICD-10 code; use for all other members. Prognosis The patient s prognosis. Choose a value from the drop-down list. Req Prov Type The provider type of the requesting provider. Choose a value from the drop-down list. Req Role The code indicating the requestor s role. Choose a value from the drop-down list. Req Tel The requestor s telephone number, in format (include the area code; enter digits only). Requestor ID The provider ID of the requesting provider. Service Type The type of service being referred. Enter one of the following values: Subscriber and Dependent Outpatient Transactions: 50 = Hospital Outpatient (Nutritional Counseling) 2013 Emdeon Business Services LLC. All rights reserved. Page 6

11 Requests 53 = Hospital (Ambulatory Surgical) 61 = In-Vitro Fertilization A4 = Psychiatric (Neuropsychological Testing) AD = Occupational Therapy AE = Physical Therapy AF = Speech Therapy AG = Skilled Nursing Care (Home Skilled Nursing Care) BF = Pulmonary Rehabilitation BG = Cardiac Rehabilitation Subscriber and Dependent Home Health Transactions: 42 = Home Health Care (Global) 44 = Home Health Visits (Home Health Aid) Subscriber and Dependent Ambulance Transactions: 56 = Medically-Related Transportation 59 = Licensed Ambulance Skilled Nursing Whether the facility is a skilled nursing facility. Choose a value from the drop-down list. Surgery Date The date of surgery, in MMDDYY format. Svc Date Begin Requirement: For outpatient and ambulance services, required if you do not enter a Proc Date. For home health services, required. The first service date, in MMDDYY format. Svc Date End Requirement: For outpatient and ambulance services, required if you do not enter a Proc Date. For home health services, required. The last service date, in MMDDYY format. The default value is the same date you entered as the beginning date of service Emdeon Business Services LLC. All rights reserved. Page 7

12 Requests Svc Prov ID The provider ID of the servicing provider. It is recommended that you match the ID (whether payer-assigned or NPI) currently in use by the service provider. Outpatient Review: For independent physical therapists (PT) or speech therapists (SLP) with sixcharacter provider IDs, enter four leading zeros (0000). If the requestor s role is as performing provider (PE), enter the referring provider s provider ID. Home Health and Ambulance Review: If the requestor s role is as performing provider (PE), enter the referring provider s provider ID. Svc Prov Type The provider type of the servicing provider. Choose a value from the drop-down list. Trnsprt Code Used in: Ambulance transactions. The code indicating the type of transport. Choose a value from the drop-down list. Trnsprt Dist Used in: Ambulance transactions. The distance the patient was transported, in miles. Trnsprt Reason Used in: Ambulance transactions. The code indicating the reason for the transport. Choose a value from the drop-down list: A = Patient was transported to nearest facility for care of symptoms, complaints, or both. B = Patient was transported for the benefit of a preferred physician. C = Patient was transported for the nearness of family members. D = Patient was transported for the care of a specialist or for availability of specialized equipment. E = Patient Transferred to Rehabilitation Facility. Visits The number of visits required Emdeon Business Services LLC. All rights reserved. Page 8

13 Responses Responses About Your Responses All of the items described in the following response explanation may not appear in every response. The database will return only the information that is applicable to your query. If the database 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. Additional Reference Documents More information about your response can be found in the following documents: PC-Standard-Health-Care-Service Review-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 Emdeon received a valid response. Read your response for clarification. Retry Emdeon did not receive a valid 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. Input Information The Input Information section (or the labeled fields in the Input/Response Information section) shows the information you entered in your inquiry. Response or (On File) Information No response data will appear in this section Emdeon Business Services LLC. All rights reserved. Page 9

14 Responses Health Care Service Review This section returns reference information for this particular transaction such as: The transaction reference number. The type of certification: Complete Term Expired Certified in Total Not Certified Pended Modified Cancelled Contact Payer No Action Required The provider ID of the requesting provider. The requesting provider s name. The requesting provider s specialty. If the requesting provider was rejected, this information describes the error condition associated with the rejection. Up to three possible reject reasons can appear. A follow-up message to the preceding reject reason. The subscriber ID of the subscriber. The subscriber s name and date of birth. The dependent s name and date of birth. Up to 12 diagnosis codes associated with the certification number, and their corresponding descriptions. If the patient was rejected, this information describes the error condition associated with the rejection. Up to three possible reject reasons can occur. A follow-up action message for the preceding reject reason. Up to three follow-up action messages can appear, one for each reject reason. Review Detail The Review Detail section contains details about the requested services, such as the servicing provider or facility, procedure codes, certification number and action. Can include the following: The type of service provider. The provider ID of the service provider. The service provider s name. The service provider s specialty. The service provider s phone number. A free-form message about the servicing provider or specialty. The type of facility that will render services to the patient; for example: Performing Ordering 2013 Emdeon Business Services LLC. All rights reserved. Page 10

15 Covering The facility ID. The facility s name. The taxonomy code and description designating the facility s specialty. The facility s telephone number. A free-form message about the facility. BlueCross BlueShield of Massachusetts Health Services Review Responses The type of group or practice that will render services to the patient; for example: Performing Ordering Covering The group practice ID. The name of the group practice. The group practice s telephone number. A free-form text message about the group or practice. If the service provider was rejected, this field describes the error associated with the rejection. Up to three possible reject reasons can appear. A follow-up action message for the preceding reject reason. Up to three follow-up action messages can appear, one for each reject reason. The review s certification number. The action code (Cert Action) for the requested procedure. If the procedure was rejected, the reason for the rejection. Up to 12 procedure codes associated with the certification number, and their associated descriptions. The authorized quantity of the corresponding procedure (1 through 12). The begin and end dates of the corresponding procedure. Any additional messages relating to the corresponding procedure. The service type code and description identifying the classification of service requested. The effective and termination date of the requested service. The pattern of delivery of the service. The place of service, i.e., type of facility, where the services will be/were performed. The proposed or actual admission date (Admission Review only). The type of ambulance transport; for example, Initial Trip Return Trip Transfer Trip Round Trip If the service was rejected, an error condition associated with the rejection. Up to three possible reject reasons can appear. A follow-up action message for the preceding reject reason. Up to three follow-up action messages can appear, one for each reject reason Emdeon Business Services LLC. All rights reserved. Page 11

16 Error Messages BlueCross BlueShield of Massachusetts Health Services Review Responses 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: Emdeon Business Services LLC. All rights reserved. Page 12

17 Index Index A About the Transaction, 1 About Your Responses, 9 Accident Country, 2 Accident Date, 2 Accident State, 2 Account #, 2 Ambulance Services Review (Subscriber and Dependent), 2 Amount, 3 Auto Accident, 3 B Birth Date, 3 C Closed, 9 Customer Support, 1 D Diagnosis 2 through Diagnosis 12, 3 E Emdeon Customer Support, 1 Employ Related, 3 Error, 9 Error Messages, 12 F First Name, 3 H Health Care Service Review, 10 Hme Hlth PrcCde, 3 Hme Hlth PrcQual, 3 Home Health Services Review (Subscriber and Dependent), 2 I Input Information, 9 Input Prompts, 2 L Last AdmPrd End, 4 Last AdmPrd Strt, 4 Last Name, 4 Last Visit Date, 4 Level Of Service, 4 O Other Party Resp, 4 Outpatient Services Review (Subscriber and Dependent), 2 P Pat Dscrg FacCde, 5 Phys Contact Dte, 5 Phys Order Date, 5 Principal Diag, 5 Proc Code, 5 Proc Code Src, 5 Proc Date, 5 Procedure 2 Date through Procedure 12 Dte, 6 Procedure 2 Src through Procedure 12 Src, 6 Procedure 2 through Procedure 12, 5 Prognosis, 6 R Req Prov Type, 6 Req Role, 6 Req Tel, 6 Requestor ID, 6 Response or (On File) Information, 9 Retry, 9 Review Detail, 10 S Service Type, 6 Skilled Nursing, 7 Status, 9 Subscriber Health Care Services Review Transactions, 2 Surgery Date, 7 Svc Date Begin, 7 Svc Date End, 7 Svc Prov ID, 8 Svc Prov Type, 8 T Transaction Types, 2 Trnsprt Code, 8 Trnsprt Dist, 8 Trnsprt Reason, 8 V Visits, 8 M Medicare Cvg, 4 Member ID, Emdeon Business Services LLC. All rights reserved. Page 13

18 Emdeon is a leading provider of revenue and payment cycle management and clinical information exchange solutions, connecting payers, providers, and patients in the U.S. healthcare system. For more information, visit Emdeon Business Services LLC. All rights reserved Lebanon Pike, Suite 1000 Nashville, TN EMDEON.6 ( )